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11830 Westline Industrial Drive
St. Louis, Missouri 63146

CLINICAL EXAMINATION OF THE SHOULDER 0-7216-9807-7

Copyright © 2004, Elsevier, Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Health
Sciences Rights Department in Philadelphia, PA, USA: phone: (+1) 215 238 7869, fax: (+1) 215 238 2239,
e-mail: [email protected]. You may also complete your request on-line via the Elsevier
Science homepage (http://www.elsevier.com), by selecting ‘Customer Support’ and then ‘Obtaining
Permissions’.

NOTICE

Physical Therapy is an ever-changing field. Standard safety precautions must be followed, but as new
research and clinical experience broaden our knowledge, changes in treatment and drug therapy may
become necessary or appropriate. Readers are advised to check the most current product information
provided by the manufacturer of each drug to be administered to verify the recommended dose, the
method and duration of administration, and contraindications. It is the responsibility of the licensed
prescriber, relying on experience and knowledge of the patient, to determine dosages and the best
treatment for each individual patient. Neither the publisher nor the editor assumes any liability for any
injury and/or damage to persons or property arising from this publication.
Publisher

Library of Congress Cataloging in Publication Data

Ellenbecker, Todd S., 1962–

Clinical examination of the shoulder / Todd
S. Ellenbecker.
p. ; cm.
Includes bibliographical references and index.
ISBN 0-7216-9807-7
1. Shoulder–Examination. 2. Shoulder–Wounds and injuries–Diagnosis. I. Title. [DNLM:
1. Shoulder Joint–injuries. 2. Shoulder Joint–physiopathology. 3. Diagnostic Techniques and
Procedures. 4. Shoulder–injuries. 5. Shoulder–physiopathology. WE 810 E45c 2004]
RC939.E45 2004
617.5¢72044–dc22 2004046718

Acquisitions Editor: Marion Waldman

Developmental Editor: Jacquelyn Merrell
Publishing Services Manager: Linda McKinley
Project Manager: Jennifer Furey
Designer: Amy Buxton

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

To my wife and best friend—Gail
FM.qxd 5/24/04 4:23 PM Page vii

PREFACE

dvances in basic science and clinical research of the tors can be used to better understand the seemingly com-
A shoulder have significantly increased the under-
standing of the anatomy, biomechanics, and pathophysiol-
plicated terms of specificity and sensitivity. These terms are
spin and snout, and the use of these terms may make it eas-
ogy of the human shoulder. With these advances has ier to apply the concepts of specificity and sensitivity using
come an influx of clinical tests and methods used to exam- these everyday terms. Spin, used for specificity, indicates
ine the patient with a musculoskeletal shoulder injury. that specificity refers to ruling “in” conditions, whereas
The primary purpose of this book is to provide the reader snout, representing sensitivity, assists in ruling conditions
with an overview of the available research substantiating “out.” While oversimplified, these simple descriptors can
or negating the use of many clinical tests for the patient be used while reading through the often detailed research
presenting with shoulder dysfunction. In addition to sim- on many clinical tests described in this text.
ply providing a detailed description of these tests, each Finally, it is hoped that the practical information
chapter provides an overview of the primary pathology for included in the latter portion of this text on strength test-
which these tests are used and summarizes the research ing, proprioception, and functional evaluation can be used
performed on these tests to provide a level of understand- to provide the most detailed clinical examination of the
ing regarding their effectiveness. high-functioning shoulder. Understanding the clustering
The inclusion of research is not meant to confuse the of signs and symptoms obtained during the clinical exam-
reader, but rather to allow for a more scientific approach ination processes inherent in the “master” clinician’s clini-
to the examination process. Repeated use of the terms cal behaviors is summarized in the final section of this
specificity and sensitivity can be at times intimidating. book in the form of case studies. It is hoped that this book
However, these statistical values can assist the clinician in will provide a valuable clinical reference tool for the prac-
identifying clinical tests that are the most effective for ticing clinician by consolidating practical and research-
patients with shoulder dysfunction. Two simple descrip- specific information in one place.

vii
FM.qxd 5/24/04 4:23 PM Page ix

ACKNOWLEDGMENTS

hile many individuals have provided guidance, I would also like to thank the physicians, therapists,
W both in this project and throughout my career, I
would like to acknowledge the following, whom this book
tennis teaching professionals, and coaches for the daily
opportunity to examine and treat their patients and
could not have been written without—George Davies, athletes and allow me the privilege to focus on clinical
Janet Sobel, Kevin Wilk, Dr. Ben Kibler, and Dr. Robert practice and research of the shoulder.
Nirschl—for their excellence and guidance in teaching me
shoulder examination and treatment.

ix
Ch01.qxd 5/24/04 4:25 PM Page 3

CHAP TER
Introduction to Clinical
1 Examination of the Shoulder

HOW TO USE THIS BOOK actually have the condition (Portney & Watkins, 1993).
This book is designed to present the integral parts of the The sensitivity of a test increases as the number of persons
examination process, combined with clinical research who are correctly identified as having the condition
identifying the effectiveness of the procedures and tech- increases. Another way of thinking of sensitivity is that it
niques used by clinicians, to evaluate the patient with increases when fewer persons with the disorder are
shoulder dysfunction. The research provided in this text missed. Obviously, it is advantageous for a clinician to use
provides crucially important information for the clinician tests that have high indexes of sensitivity.
and contains specific terms, such as specificity, sensitivity,
and predictive value. A discussion of these terms is war- Specificity
ranted to improve the application of this research to the Specificity is the ability of a test to obtain a negative result
clinical evaluation process. when the condition the clinician is testing for is truly
absent. Specificity is represented by the proportion of
Definition of Key Terms individuals who test negative for the condition out of
The use of terms such as specificity, sensitivity, and both all those who do not have the condition. According to
positive and negative predictive value are commonly applied Portney and Watkins (1993), a highly specific test will
in research reporting the accuracy and effectiveness of rarely test positive when a person does not have the
examination techniques on patients. In many studies, disease or condition for which he or she is being tested.
patients are examined clinically and results are compared
to determine the reliability of the clinical test both for one Combining Sensitivity and Specificity
examiner on numerous occasions of testing (intrarater Obviously, using tests with high sensitivity and specificity
reliability) and among several examiners (interrater relia- enhances a clinician’s ability to correctly identify patholo-
bility). Clinical tests contained in this book are also often gy and arrive at the best possible clinical impression and
compared with the results of other diagnostic tests such subsequent treatment plan. As with many clinical scenar-
as magnetic resonance imaging (MRI) or radiographs, ios, however, there are tradeoffs between the two charac-
as well as with intraoperative findings. The presence of teristics. Tests that are designed to be highly sensitive have
injury or pathology at time of surgery confirms or negates testing criteria that are typically less stringent; thus fewer
the result of clinical testing and is a common research cases are missed (Portney & Watkins, 1993). In this
design presented in this book. scenario, the chances of obtaining false-positive results
increase (decreased specificity) because less stringent qual-
Sensitivity ifying responses are used to render a test positive. Like-
The validity of a screening or evaluation test is measured wise, if the test criteria are made more stringent, such that
in terms of its ability to accurately assess the presence or only a narrow range of individuals with the criterion vari-
absence of the target condition (Portney & Watkins, able will test positive, a greater proportion of those who are
1993). Sensitivity can be defined as the ability of a test or normal will test negative (increasing specificity); however,
evaluation maneuver to obtain a “positive” result when the a larger number of the true cases (individuals who have the
condition the test is testing for is really present. In other condition) will be missed, which decreases sensitivity.
words, sensitivity is the ability of the test to produce a true Sensitivity is most important when the risk associated
positive result when the patient being tested actually has with missing a diagnosis is high, such as identifying can-
the disorder for which the examiner is testing. Sensitivity cer or other life-threatening disease. Using the muscu-
is represented by the percentage of individuals who test loskeletal tests mentioned in this book, including the
positive for the condition out of all those individuals who clinical elimination maneuvers for the glenoid labrum,

3
Ch01.qxd 5/24/04 4:25 PM Page 4

4 SECTION I General Overview

which may render a patient a candidate for a surgical pro- posture that does not allow further testing as a result of
cedure, would also carry a high risk, as an inaccurate diag- decreased relaxation. Therefore careful selection of the
nosis may subject a patient to an unnecessary surgical most important and clinically accurate tests is an impor-
procedure. Specificity is more important when either the tant responsibility of the clinician when performing a
costs or risks involved with further intervention are sub- clinical shoulder examination.
stantial (Portney & Watkins, 1993). This book includes
Prevalence
multiple tests in most areas to provide the clinician with a
variety of clinical tests, so that the results of several exam- The concept of prevalence must be considered when
inations can be combined to minimize the tradeoffs applying and interpreting clinical tests. The term preva-
between specificity and sensitivity. lence refers to the number of cases of a condition that exist
in a certain population at any given time (Portney &
Predictive Value Watkins, 1993). When the prevalence is high, the likeli-
To determine whether the performance of a clinical test or hood of identifying cases correctly using tests with a given
series of clinical tests is feasible and an efficient use of sensitivity and specificity increases. Also, when prevalence
both the examiner’s and patient’s time, the test’s predictive is high, a test will tend to have a higher PPV. When
value can be assessed. Positive predictive value (PPV) esti- prevalence is low, the chances of obtaining a false-positive
mates the likelihood that a person who tests positive will result are much higher than when the prevalence of a par-
actually have the condition for which he or she is being ticular condition is high. When using the empty or full
tested. PPV is the proportion of patients who test positive can test to detect a full-thickness rotator cuff tear, knowl-
and who truly have the condition. A clinical test with a edge regarding the prevalence of rotator cuff tears plays a
very high PPV provides a strong estimate of the number considerable part in applying the results of the test. For
of patients who actually have the condition. example, when testing an 11-year-old elite junior tennis
Likewise, negative predictive value (NPV) indicates player with anterior shoulder pain, a positive empty or full
the probability that a person who tests negative on a clin- can test is unlikely to indicate a full-thickness tear of the
ical test actually does not have the condition for which he supraspinatus tendon, as full-thickness rotator cuff tears
or she is being assessed. Research by Itoi et al (1999) illus- in that young population are less common and occur at a
trates the concept of predictive value. They studied the very low prevalence. In contrast, if the empty or full can
effectiveness of the empty and full can clinical tests in test resulted in significant muscular weakness in a 79-
identifying patients with full-thickness rotator cuff tears. year-old competitive tennis player with anterior shoulder
By using the criterion of muscular weakness, the full can pain, the likelihood that this finding would indicate a full-
clinical test had a PPV of 49%. This finding tells clini- thickness tear is much greater because of the greater
cians that approximately one of every two patients who prevalence of full-thickness tears in older individuals.
have substantial weakness during the performance of the Summary
full can rotator cuff test actually has a full-thickness rota- This book provides detailed descriptions of clinical tests
tor cuff tear. Likewise, one of every two patients who test along with research reporting their sensitivity and speci-
positive during the full can test is actually normal. ficity, as well as their positive and negative predictive
Applying positive and negative predictive values to the value. This information provides a better indication of the
clinical environment may at first seem overly scientific and actual effectiveness of a specific clinical test or group of
academic. However, consider the ramifications of using a clinical tests, as well as a better understanding of the role
clinical test with a very low PPV during the evaluation of that an examination maneuver or group of maneuvers can
a patient who presents with symptoms consistent with a play in the comprehensive evaluation of the patient with
labral tear. If an individual were to test positive for a labral shoulder pathology.
tear using a test with a very low PPV, considerable time
and additional resources would be required to further COMPARISON OF CLINICAL
determine whether that initial clinical test was actually EVALUATION FINDINGS WITH
correct. In some cases, the use of clinical tests with a very OTHER DIAGNOSTIC TESTS AND
low PPV or NPV is not worth the potential discomfort SURGICAL FINDINGS
and time required. Another potential problem with using One of the most common methods of determining the
tests with low predictive value is that alternative tests are effectiveness of a group of clinical examinations of the
often required to confirm the results of the first test. For shoulder is to compare the results with established diag-
example, use of a clunk test to identify labral pathology nostic tests. Naredo et al (2002) compared the results of
may place the patient in a more apprehensive clinical physical examination to ultrasound testing in 31 consecu-
Ch01.qxd 5/24/04 4:25 PM Page 5

CHAPTER 1 Introduction to Clinical Examination of the Shoulder 5

tive patients with a first episode of shoulder pain. Exami- tion 51% of the time and with the diagnostic categories
nations were performed by two rheumatologists, with a 80% of the time (Magarey et al, 1989). Further research
third rheumatologist blinded to the results of the clinical on the use of diagnostic categories as well as continued
examination performing the ultrasound. The clinical comparison of clinical test results with arthroscopic
examination consisted of active and passive range of evaluation will assist in determining accuracy and guide
motion and 10 special examination maneuvers. Results of therapists in both the performance and especially the
the comparison showed very low sensitivity in the clinical interpretation of clinical examination methods for the
diagnosis of nearly all shoulder lesions, especially rotator shoulder.
cuff tears; however, specificity was high for rotator cuff
tear, tendonitis of the subscapularis and infraspinatus, and
acromioclavicular joint injury. Specificity was very low for GENERAL CONCEPTS APPLIED
supraspinatus tears, biceps tendonitis, and rotator cuff DURING CLINICAL EXAMINATION
impingement. This study emphasized that pain elicited OF THE SHOULDER
during impingement testing by placing the rotator cuff Several general concepts are important when performing
beneath the acromial arch can be diagnostic for many clinical examination of the shoulder. These concepts are
types of rotator cuff lesions, and the induced pain cannot referred to throughout this book, but are described in
be clearly diagnostic for one particular condition. The detail here. They are essential to the successful examina-
authors concluded that clinical assessment by experienced tion of the patient with shoulder pathology.
physician examiners of the patient with a first-time
injured shoulder was often inaccurate and that ultra- Resting Position of the Glenohumeral Joint
sonography should be used whenever possible to improve The resting position of the human glenohumeral joint is
diagnostic accuracy. generally considered to be the position of maximum range
Research results comparing MRI with clinical evalua- of motion and laxity, as a result of minimal tension or
tion is also available. These studies are covered in greater stress in the supportive structures surrounding the joint
detail in Chapter 13. MRI has been reported to have a (Hsu et al, 2002). This position has been referred to as the
high sensitivity (100%) and specificity (95%) for the diag- loose-pack position of the joint. Kaltenborn (1989) and
nosis of rotator cuff tears (Ianotti et al, 1991) and can dif- Magee (1997) have both reported that the resting position
ferentiate normal rotator cuff tendons from tendons with of the glenohumeral joint ranges between 55 and 70
“tendonitis” (93% sensitivity, 87% specificity). degrees of abduction (trunk humeral angle) in the scapu-
Liu et al (1996a) introduced the crank test for clinical lar plane (see definition of scapular plane in this chapter).
identification of labral tears and reported a higher sensi- This loose-pack position is generally considered to be in
tivity of 90% compared with sensitivity of MRI (59%) and mid-range position, but only recently has been subjected
a specificity that equaled that of MRI (85%). This study to experimental testing.
found that a clinical test was more accurate than MRI in Hsu et al (2002) measured maximal anteroposterior
identifying labral tears in 62 patients who had an average displacements and total rotation range of motion in
of 3 months of shoulder symptoms that did not resolve cadaveric specimens, with different positions of gleno-
with physical therapy. humeral joint elevation in the plane of the scapula. They
Finally, comparison of clinical examination findings identified the loose-pack position, where maximal antero-
with arthroscopic shoulder surgery continues to be one of posterior humeral head excursion and maximal total rota-
the more common means to measure the validity of clini- tion range of motion occurred within the proposed range
cal tests. Itoi et al (1999) used this approach to study the of 55 to 70 degrees of humeral elevation in the scapular
effectiveness of the empty and full can clinical test to plane (trunk-humeral angle) at a mean trunk humeral
identify supraspinatus tears. Magarey et al (1989) com- angle of 39.33 degrees. This rate corresponded to 45% of
pared the results of a clinical examination of the shoulder the available range of motion of the cadaveric specimens.
by two physical therapists with findings obtained during Anteroposterior humeral head translations and maximal
arthroscopic surgery. The two therapists independently total rotation ranges of motion were significantly less, at 0
reached the same conclusion regarding the “tissue source” degrees of abduction and near 90 degrees of abduction
of the patient’s pain 100% of the time. There was 72% in the plane of the scapula, and were greatest near the
agreement in their ability to place the patient into one of experimentally measured resting position of the gleno-
four diagnostic categories: impingement, tendonitis, humeral joint. This study provides key objective evidence
tendon rupture, and instability. The use of arthroscopy for the clinician to obtain the maximal loose-pack posi-
to identify tissue source agreed with the clinical examina- tion of the glenohumeral joint by using the plane of the
Ch01.qxd 5/24/04 4:25 PM Page 6

6 SECTION I General Overview

Figure 1-1 Balance point position allowing clinician to support the patient’s extremity with one hand. Note the position of the hand
near the epicondyles of the elbow.

scapula and approximately 40 degrees of abduction. This retically required to allow for full overhead elevation in
information is important to clinicians who wish to evalu- the scapular plane (Inman et al, 1944). Throughout this
ate the glenohumeral joint in a position of maximal excur- book, the scapular plane position is used during specific
sion or translation to determine the underlying accessory evaluation techniques, including humeral head translation
mobility of the joint. tests and impingement tests.
This cadaveric research provides additional clinical
guidance for identifying relative or percent of abduction Balance Point Position of the Upper Extremity
range of motion where this position occurs. In patients The balance point position concept, used frequently in
with restrictions in humeral elevation resulting from clinical tests to evaluate the glenohumeral joint, is not
capsular tightness, the loose-pack position occurs in less technically based on a calculated or measured balancing
abduction than in individuals with full range of abduction point for the human upper extremity. Rather, this concept
range of motion. Clinicians should use this information refers to the position the clinician can use when grasping
during both evaluation and treatment of the human and supporting the patient’s extremity with only one
shoulder. hand, allowing use of the other hand for additional stabi-
lization or function.
Scapular Plane Position Figure 1-1 shows the approximate position and grip
According to Saha (1983), the scapular plane is defined that can be used to control or balance the patient’s upper
as being 30 degrees anterior to the coronal or frontal plane extremity. This position is referred to throughout this
of the body. Placement of the glenohumeral joint in the book as the balance point position. Note the location near
scapular plane optimizes the osseous congruity between the elbow and the use of the fingers and thumb to opti-
the humeral head and the glenoid and is widely recom- mize contact on a rather wide area at the elbow. This posi-
mended as an optimal position for performing both tion allows the clinician to influence humeral rotation, as
various evaluation techniques and many rehabilitation well as move the glenohumeral joint in flexion, abduction,
exercises (Saha, 1983; Ellenbecker, 1995). With the and circumduction. Care should be taken to avoid overly
glenohumeral joint placed in the scapular plane, bony aggressive grasping of the patient’s elbow, as this can lead
impingement of the greater tuberosity against the to an increase in patient apprehension and unwanted
acromion does not occur because of the alignment of the muscular activation. Repetitive practice with both the
tuberosity and acromion in this orientation (Saha, 1983). clinical tests and patient contact enables the clinician to
Also, no internal or external rotational movement is theo- use optimal patient contacts throughout the upper ex-
Ch01.qxd 5/24/04 4:25 PM Page 7

CHAPTER 1 Introduction to Clinical Examination of the Shoulder 7

tremity and ensures that an adequate amount of pres- that is widely recommended and followed closely is the
sure is used to stabilize and handle the patient’s extremity, ordering of the initial extremity to be evaluated. It is
while avoiding a painful or apprehensive response. recommended that the examiner perform clinical test pro-
cedures on the uninjured extremity first, followed by the
Extremity Examination Sequence involved extremity. Following this order promotes greater
The sequence of actual tests used in shoulder evaluation patient relaxation during examination of the involved
varies based on several factors. Although each clinician or extremity, which is often painful, and reduces the appre-
educator may prefer a specific sequence of elements when hension often encountered during the examination
performing the shoulder examination, few objectively process because the patient may be unsure of which move-
based criteria exist. One aspect of the examination process ments or maneuvers the examiner will be performing.
Ch02.qxd 5/24/04 4:26 PM Page 9

CHAP TER

2 Examination: Patient History

INTRODUCTION reader is referred to a summary of nonmusculoskeletal

A thorough, organized history of the patient with shoul- causes of shoulder region pain in Chapter 5. To perform
der dysfunction is required in the complete examination a complete and thorough patient examination, careful
process. It is important to include both general questions analysis of subjective information provided in the patient’s
with regard to shoulder pathology and specific questions history is required to alert the examiner to the possible
based on the patient’s sport or activity. Although there are presence of nonmusculoskeletal causes. This information
many approaches to history taking, one example of a thor- directs the clinician to a broader base of examination tech-
ough history applicable for a patient with shoulder dys- niques and possible referral to specialists to rule out non-
function is listed in Box 2-1. This chapter covers several musculoskeletal contribution of shoulder dysfunction.
areas of the patient history in greater detail.
PAST HISTORY
IMMEDIATE HISTORY A thorough understanding of the patient’s past history of
One of the initial areas of focus on the subjective evalua- shoulder injury and disability is essential to a successful
tion is the patient’s immediate history, which typically subjective evaluation. Using the example of a patient with
includes the chief complaint. Although many types of shoulder instability, it is important to delineate whether
questions can be asked, the following four questions sum- the patient has “one time” anterior dislocation from a
marize one approach to obtaining the immediate history: traumatic event (TUBS classification of Matsen [Trau-
1. What is the problematic area? matic, Unidirectional, Bankart, Surgery]) or a repeated,
2. How did the problem occur? chronic instability of the glenohumeral joint from repeti-
3. When did the problem develop? tive stresses and an acquired atraumatic onset of injury
4. Where did the problem occur? (AMBRI classification of Matsen [Atraumatic, Multi-
Although these questions may seem simplistic, they can directional, Bilateral Laxity, Rehabilitation, Inferior
effectively elicit the basic information required from the Capsular Shift]). Knowledge of the patient’s pertinent
patient (Maughon & Andrews, 1994). past shoulder history influences not only the sequence and
The description of the chief complaint or complaints inclusion of specific tests used in the evaluation but
typically involves pain, weakness, instability, sensory treatment procedures as well. Examination of a mature
changes, and crepitus. Attempts by the examiner to quan- athlete with a rotator cuff injury from overhead activity is
tify the degree, severity, and exact location of these factors another example of the importance of obtaining a thor-
via the patient’s subjective responses involve sequential, ough history relating to shoulder pathology. Complete
organized dialogue between the patient and examiner. questioning often can reveal a fall onto the lateral aspect
During the subjective evaluation of the shoulder, attempts of the shoulder as long ago as 20 to 30 years or a shoulder
should be directed toward delineating and localizing the separation in high school football that can shed light on
symptoms to the injured segment or segments. Identifica- the patient’s impingement-type symptoms. Encroach-
tion of radicular symptoms into the distal upper extrem- ment of the subacromial space as a result of degenerative
ity, constant pain without change or relief, and the changes in the acromioclavicular joint from previous
presence of headaches, low back or neck pain, and psy- injury has been reported as an etiologic factor in impinge-
chosocial stresses that may be influencing the patient’s ment lesions (Neer, 1983).
overall health provide rationales for further objective Specific questioning regarding previous treatment
evaluation outside the upper extremity kinetic chain. For to the injured shoulder is also of interest to the rehabilita-
a more detailed discussion of differential diagnosis, the tion specialist. Previous surgical procedures, steroid

9
Ch02.qxd 5/24/04 4:26 PM Page 10

10 SECTION I General Overview

Box 2-1 Examination: History

• Chief complaint
• Nature of symptoms
• Behavior of symptoms
• Location of symptoms
• Onset of symptoms A
• Course and duration of symptoms
• Effect of previous treatment
• Other related medical problems

Adapted from Saunders HD: Evaluation of a musculoskeletal disorder.

In Gould JA, Davies GJ: Orthopaedic and sports physical therapy, St Louis,
1985, Mosby.

injections, therapeutic modalities, and exercise programs

are relevant when formulating an evaluation-based treat-
ment program.

LOCATION OF SYMPTOMS
B
Determining the location of symptoms is an important
part of the subjective evaluation and is required to
enhance the objective portion of the evaluation process.
Isolating the area of discomfort is often difficult for the
patient with an overuse injury to the rotator cuff because
of the intimate association of the tendons of the rotator
cuff to one another near their humeral insertion (Clark & Figure 2-1 Pattern of pain presentation after localized injection
into A, the acromioclavicular joint, and B, the subacromial space.
Harryman, 1992). The splaying and interweaving of the (From Gerber C, Galantay RV, Hersche O: The pattern of pain
rotator cuff, as well as an ensheathed biceps tendon by the produced by irritation of the acromioclavicular joint and the sub-
subscapularis and supraspinatus tendon, may further com- acromial space, J Shoulder Elbow Surg 7(4):353, 1998.)
plicate the isolation of a direct point of injury in these
structures (Clark & Harryman, 1992). Identification of
referral symptoms into the lateral aspect of the shoulder,
or continuing into the elbow and distal upper extremity, Injection into the subacromial space produced a charac-
indicates the need for further objective testing and speci- teristic pain pattern, which included mainly the region
fic joint clearing tests to rule out involvement of the cer- overlying the lateral aspect of the deltoid in 100% of the
vical spine or elbow joints (Davies & DeCarlo, 1995). subjects injected (see Figure 2-1). All 10 subjects also had
Confirmation of the location of patient symptoms is often pain over the lateral border of the acromion. The acromio-
achieved through the use of a body chart. clavicular joint remained pain free in every case when
Gerber et al (1998) attempted to characterize pain injection was directed into the subacromial space.
patterns after an isolated injection of a hypertonic saline This important study provided evidence regarding the
solution directly into the subacromial space and acromio- typical pain patterns expected with irritation of either the
clavicular joint. Figure 2-1 shows the pain patterns subacromial space or acromioclavicular joint. It also char-
produced by the injections. Injection of the hypertonic acterized normal pain responses for irritation of these
saline into the acromioclavicular joint produced relatively structures and identified the lack of posterior scapular and
isolated symptoms directly over the joint in all subjects. neck symptoms from isolated irritation of either the sub-
Pain was also reported over the anterolateral neck region acromial space or acromioclavicular joint (Gerber et al,
and along the upper trapezius muscle, with extension dis- 1998). One of the most common patterns of radicular
tally to the anterolateral deltoid. This injection into the pain that can be confused with shoulder dysfunction is the
acromioclavicular joint produced palpable soreness over C6 radiculopathy. This pain is often referred to the shoul-
the joint, as well as tenderness over the coracoid in 87% of der, the anterosuperior aspect of the arm, the radial aspect
the subjects injected. Pain produced by cross-body abduc- of the forearm, and the thumb (Adams, 1977). This pat-
tion increased after injection in only 13% of the subjects. tern is similar to the one described by Gerber et al (1998)
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CHAPTER 2 Examination: Patient History 11

for the acromioclavicular joint, except for the presence of because of the possibility of encroachment of the subacro-
posterior neck pain and exacerbation of the pain with mial space when the scapula is protracted.
movements of the cervical spine in cases of C6 radicu- An additional series of questions directed at the
lopathy. Weakness or abnormal C6 reflexes and a lack of patient’s sport or activity demands provides important
tenderness directly over the acromioclavicular joint inher- information for the clinician. For example, establishing
ent in cases of C6 radiculopathy further assist the clinician that a throwing or racquet sport athlete has pain when
in differentiating between acromioclavicular joint injury throwing or serving does not provide the appropriate level
and C6 radiculopathy. of information necessary to properly diagnose and formu-
C7 nerve root compression affects the pectoral region, late a treatment plan. Further questioning as to what
the medial axilla, the region of the scapula, and the tri- stages of the throwing or serving motion produce the
ceps, as well as the dorsal aspect of the forearm and elbow symptoms and after how many repetitions may provide
and middle finger (Gerber et al, 1998). Tenderness is insight into what structures are involved. Specific muscu-
often most noted over the vertebral border of the scapula lar activity patterns and joint kinematics inherent in each
opposite vertebral segments T3 and T4 (Adams, 1977). stage of the throwing motion and tennis serve can assist in
This pattern is uniquely different from the patterns identifying compressive disease or tensile-type injuries of
identified in the evidence-based research of Gerber et al the rotator cuff. The presence of instability of the gleno-
(1998). Their study showed the importance of the history humeral joint, however subtle, during the cocking phase
and physical examination in distinguishing pain arising in of overhead activities can produce impingement or com-
structures intimately associated with the glenohumeral pressive symptoms ( Jobe & Bradley, 1989; Walch et al,
joint versus more central pathology. 1992), whereas a feeling of instability or loss of control
during the follow-through phase during predominant
SEVERITY OF SYMPTOMS eccentric loading of the rotator cuff can indicate a tensile
The use of analog scales is typically recommended for rotator cuff injury (Andrews & Alexander, 1995). Addi-
quantification of the subjective response of pain severity. tional questions regarding a change in sport equipment,
The patient’s rating on a 10-point scale at rest and with ergonomic environment, and training history/habits pro-
activity or specific activities allows for comparison vide information that is imperative for understanding the
between visits and after treatment or activity trials. Using stresses leading to the injury. Examples of additional spe-
the analog scale involves asking the patient to rate the cific questions used during the examination of a baseball
pain, with “0” being no pain and “10” being the worst pain or tennis player are provided in Boxes 2-2 and 2-3.
ever encountered. Other scales are also used to quantify
the patient’s pain. These scales are generally used to eval-
uate the outcome of a specific surgical procedure or to
determine the effectiveness of a treatment process. Refer ACTIVITIES OF DAILY LIVING,
to Chapter 15 for a complete discussion of subjective VOCATIONAL, AND AVOCATIONAL
rating scales. The use of analog and subjective rating GOALS
scales provides additional information for the subjective The individual’s goals play an important part in the for-
evaluation to complement the patient’s report of pain. mulation of an evaluation-based treatment program.
Knowledge of the patient’s vocation and avocational activ-
GENERAL QUESTIONS ities and goals assists the clinician by allowing the use of
Additional questions specifically for the patient with more specific and functionally oriented evaluation and
shoulder pathology are recommended. One question treatment methods. Testing the shoulder in positions
involves the presence of night pain and sleeping position. required either in sport- or activity-specific movement
In a magnetic resonance imaging study (Solem-Bertoft et patterns is required for each shoulder to completely eval-
al, 1993), the subacromial space was narrower in a position uate the degree and level of injury and begin the formula-
of scapular protraction as compared with scapular retrac- tion of a treatment program. The patient’s symptoms can
tion. In a patient suffering from primary glenohumeral be more adequately elicited when specific positions, as
joint impingement, the side-lying position (i.e., lying on well as mode and force-specific muscular contractions, are
the involved side during sleeping) is not beneficial at rest used in the evaluation process.
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12 SECTION I General Overview

Box 2-2 Examination: History of the Box 2-3 Examination: History in the
Throwing Shoulder Tennis Player
I. General Information I. Presence of Pain during Specific Stroke
A. Age A. Forehand
B. Dominant Arm (Throwing) 1. Preparation
C. Bats (Left, Right, Switch) 2. Acceleration
D. Years Throwing 3. Ball contact
1. Years pitching 4. Deceleration/follow-through
2. Years in other positions B. Backhand
E. Level of Competition 1. One-handed backhand
II. Medical Information 2. Two-handed backhand
A. Chronic or Acute Problem 3. Phase of pain development as in forehand
B. Review of Systems above (I–IV)
C. Preexisting or Recurrent Shoulder Problem C. Serve/Overhead
D. Other Musculoskeletal Problems 1. Cocking phase
1. Acute 2. Acceleration phase
2. Distant to shoulder (kinetic chain 3. Deceleration/follow-through phase
involvement) D. Volleys
III. Shoulder Complaints 1. Forehand
A. Symptoms (Specify Pitching Versus Throwing) 2. Backhand
1. Pain a. One-handed versus two-handed volley
2. Weakness or fatigue II. Specific Mechanism
a. Loss of velocity A. Single Stroke (Acute Onset)
b. Loss of accuracy B. Overtraining (Gradual Onset)
3. Instability/subluxation C. Able to Continue Playing
4. Stiffness (inability to get “loose”) 1. Without stroke modification
5. Catching/locking 2. With stroke modification
B. Injury Pattern III. Training History
1. Sudden onset or acute onset (pitching A. Change in Technique?
versus throwing) 1. Grip
2. Gradual or chronic onset (pitching versus 2. Stance
throwing) 3. Other
3. Traumatic onset—fall or blow to extremity B. Change in Coach
4. Recurrent pattern C. Change in Training Program
C. Symptom Characteristics 1. Surface
1. Location 2. On-court training
2. Character and severity 3. Off-court training
3. Provocation IV. Equipment
4. Duration A. Racquet
5. Paresthesias/referral pattern 1. Type
6. Phase of throwing or pitching 2. How long with current frame
a. Cocking phase 3. Modifications to current frame
b. Acceleration phase a. Weight
c. Deceleration phase 4. Previous frame
7. Related activities/disability B. String
D. Related Symptoms 1. Type
1. Cervical 2. Tension
2. Peripheral nerve 3. Change in tension/type?
3. Brachial plexus V. Ability to Play Presently
4. Entrapment A. Certain Strokes Pain-Free
B. Stroke Modification Required
Adapted from Gillogly S, Andrews JR: In Andrews JR, Zarins B, Wilk
KE, eds: Injuries in baseball, Philadelphia, 1998, Lippincott.
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CHAP TER

3 Observation/Posture

INTRODUCTION combinations. Females should be evaluated while wearing

Evaluation of a patient’s posture has been regarded as a a gown or sports bra to preserve patient modesty. Clear
crucial part of the comprehensive examination of a patient visual inspection of the shoulder region and scapula is
with spinal dysfunction. Gould stated, “the static and essential for a complete postural evaluation.
dynamic posture of the client can add insight to muscu-
loskeletal problem solving,” and the importance of a com- SHOULDER HEIGHT ASSESSMENT
prehensive evaluation of posture is no less important in The relative height of the shoulders should be assessed
the patient with shoulder dysfunction. Gould also stated, because this can provide significant information about
“the clinician should attempt to gain awareness not only the patient’s muscular development, as well as the pres-
of gross alterations in posture such as shoulder heights or ence of any guarding through exaggerated use of the
iliac crest height, but also of subtle changes in muscle tone upper trapezius musculature. Typically, the dominant
or subtle disruptions in rhythm” (Gould, 1985). shoulder is lower than the nondominant shoulder in
Evaluation of sitting and standing posture begins neutral, nonstressed standing postures. Although the
before the patient is aware of it. Observing the patient’s exact reason for this phenomenon is unclear, increased
seated posture in the waiting area can serve as an impor- mass in the dominant arm may cause the dominant shoul-
tant initial finding. Common alterations in sitting are der to be lower secondary to the increased weight of
extreme variations in forward head posture, which include the arm, as well as elongation of the periscapular muscu-
increases in cervical lordosis and thoracic kyphosis, as well lature on the dominant or preferred side secondary to
as a protected posture that often includes shoulder girdle eccentric loading. In addition, stretching and elongation
elevation with scapular protraction and placement of the may occur from carrying heavy objects on the dominant
arm across the stomach held closely against the body. As side. Evaluation of the patient in the standing position
the patient ambulates to the evaluation room, careful should typically show the dominant shoulder to be
observation of how the affected extremity moves during slightly lower (no normative data currently exist in the
gait also provides valuable insight into the degree of pro- scientific literature), or at least the shoulders should be
tection the patient affords that extremity. The presence of level with each other.
this protective posture provides valuable insight into how
approachable the patient may be with objective clinical ALTERATIONS IN SHOULDER HEIGHT
tests. Approaching and handling the patient’s extremity Visual observation of the patient’s shoulders from the
with both greater care and a softer touch are required if posterior and anterior views can identify alterations from
protected posturing is initially observed. the normal relationship described previously.

STANDING POSTURE EVALUATION DOMINANT, INJURED

Evaluation of the patient in the standing position is indi- SHOULDER HIGHER
cated early in the evaluation process. A male patient Visual inspection of the dominant, injured shoulder often
should be evaluated with all shirts and undershirts identifies this shoulder as higher than the uninjured, non-
removed to allow for full visualization of the shoulders dominant shoulder. This finding often indicates muscular
and spine from the waist upward. When possible, observ- guarding and lends insight to the examiner as to any
ing the patient during removal of his shirt provides exaggerated upper trapezius muscular activation that may
valuable insight into active movement capabilities and require intervention (Figure 3-1). Objective data on the
degree of hesitancy to initiate movement in various magnitude of dominant injured shoulder elevation are not

13
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14 SECTION I General Overview

Figure 3-2 Characteristic postural deviations with regard to

shoulder height of two elite level tennis players (player on left is
left-handed; player on right is right-handed). Note the lowered
dominant shoulder relative to the nondominant side.

in two elite level tennis players. Consequences of this

depression on the dominant side included thoracic outlet
syndrome, rotator cuff pathology from alteration of scapu-
Figure 3-1 Patient with guarded right shoulder position demon- lar positioning, and abutment of the rotator cuff on an
strating a higher dominant shoulder as seen after operative pro-
cedure.
altered acromial position, as well as spinal pathology
(Priest & Nagel, 1976). Of particular importance is the
finding of protraction and downward rotation of the dom-
available; however, it is recommended that this observa- inant scapula. Solem-Bertoft et al (1993) used magnetic
tional finding be noted. resonance imaging to demonstrate a narrowing of the
subacromial space when shoulders were experimentally
TENNIS SHOULDER
moved from positions of maximal retraction to protracted
“It is said that oarsman of ancient galleys developed a cor- positions. This narrowing of the subacromial space can
poreal deformity when rowing only on one side of the lead to glenohumeral joint impingement and alter normal
ship, and that a favor the slave master could bestow upon scapulothoracic and glenohumeral joint arthrokinematics.
an oarsman was to alternate him from one side of the ship Downward rotation of the scapula can also lead to a
to the other, allowing maintenance of symmetrical change in the resting posture/position of the glenoid
physique” (Priest & Nagel, 1976). The term tennis shoul- (Figure 3-3). Downward rotation secondary to postural
der has been described by Priest and Nagel (1976) to alteration can lead to a more vertical glenoid position and
describe a developmental characteristic in the dominant change the angle of inclination. Changes in the angle of
arm of tennis players, where the dominant shoulder inclination of the scapula have been reported in patients
droops inferiorly with an apparent scoliosis. The position with increases in inferior translation and multidirectional
of the shoulder girdle and scapula is one of depression, instability of the glenohumeral joint (Basmajian &
protraction, and often downward rotation. Tennis shoul- Bazant, 1959).
der exists in unilaterally dominant athletes such as tennis
players, baseball players, volleyball players, and individuals HANDS-ON-HIPS POSITION
who ergonomically use one extremity without heavy or In the standing position, the clinician can observe the
repeated exertion of the contralateral extremity (Priest & patient for symmetric muscle development and, more
Nagel, 1976; Kibler, 1991, 1998a). specifically, focal areas of muscle atrophy. One position
A total of 84 world class tennis players were initially that is recommended, in addition to observing the patient
examined by Priest and Nagel and found to have this with the arms at the sides in a comfortable standing pos-
drooping phenomenon of the dominant shoulder. ture, is the “hands-on-hips position” (Figure 3-4). This
Figure 3-2 shows this characteristic postural adaptation position places the patient’s shoulders in approximately 45
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CHAPTER 3 Observation/Posture 15

Supraspinous fossa Crest of spine

Acromion

Dorsal surface
Infraspinous fossa (posterior)

Figure 3-3 Angle of inclination of the glenoid. Note the upward

tilt of the glenoid to prevent passive downward displacement of
the humeral head. (From Basmajian JV, Bazant FL: Factors pre- Figure 3-5 Scapular fossae and landmarks.
venting downward dislocation of the adductor shoulder joint, J
Bone Joint Surg 41A:1182, 1959.)
Transverse
Suprascapular scapular Suprascapular
nerve ligament
notch

Supraspinatus
muscle
Spinoglenoid
notch

Figure 3-6 Posterior view of the scapula outlining the course of

the suprascapular nerve.

observe focal pockets of atrophy along the scapular border,

as well as more commonly over the infraspinous fossa of
the scapula (Figure 3-5).
Thorough visual inspection using this position can
often identify excessive scalloping over the infraspinous
fossa present in patients with rotator cuff dysfunction, as
well as in patients with severe atrophy who may have
suprascapular nerve involvement. Impingement of the
suprascapular nerve can occur at the suprascapular notch
or spinoglenoid notch (Figure 3-6) and from paralabral
Figure 3-4 Hands-on-hips position in a right-handed patient.
cyst formation commonly found in patients with superior
labral lesions (Piatt et al, 2002). Figure 3-7 shows the iso-
to 50 degrees of abduction with slight internal rotation. lated atrophy present in the infraspinous fossa of a patient
The hands are placed on the iliac crests of the hips, with after arthroscopic labral repair. The patient stands in the
the thumbs pointed posteriorly. This position is also used hands-on-hips position, which exaggerates atrophy and
during the Kibler lateral scapular slide test (see pages assists the clinician in identifying this physical examina-
22–25). Placement of the hands on the hips allows the tion finding. Further examination of the patient with
patient to relax the arms and often enables the clinician to extreme wasting of the infraspinatus muscle is warranted
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16 SECTION I General Overview

Table 3-1 Additional Postural Findings in

Patients with Shoulder Pathology
Typical Indication
Patient Presentation of Posture
Prominent acromion Glenohumeral joint
dislocation
Laterally depressed scapula
Slightly abducted humerus
“Stairstep” drop-off of the Acromioclavicular
lateral aspect of the separation
clavicle above the
acromion
“Popeye” biceps appearance Biceps long head
tendon rupture
Scapula grossly Scapular winging
disassociated from the from long thoracic
thoracic wall nerve involvement
Figure 3-7 Patient with significant atrophy in the infraspinous
fossa. Patient in hands-on-hips position after superior labral repair. Adapted from Halbach JW, Tank RT: The shoulder. In Gould JA, Davies
GJ, editors: Orthopaedic and sports physical therapy, St Louis, 1985,
Mosby.

to rule out suprascapular nerve involvement. The use of The incidence of scoliosis in unilaterally dominant ath-
nerve conduction tests, in addition to a detailed physical letes, even at very young developmental ages, has been
examination, can lead the clinician to the diagnosis of reported secondary to asymmetric muscular development
suprascapular nerve injury. and sport-specific upper body loading patterns (Priest &
Nagel, 1976). Methods of assessment for spinal curvature
ADDITIONAL POSTURAL TESTS include solely visual observation, as well as visual observa-
IN STANDING tion with the assistance of a plumb line or posture grid
Assessment of spinal position, in addition to shoulder (Davies & DeCarlo, 1995), in addition to radiographs.
height, is also important during this phase of the evalua- Evaluation of the patient using a maneuver known as the
tion process. The spine should be inspected from posterior Adam’s position (American Academy of Orthopaedic
and lateral views to assess for the presence of the charac- Surgeons, 1992; Grossman et al, 1995) involves placing
teristic curvature of the spine in the sagittal plane and lack the patient in a forward-flexed spinal posture between 45
of curvature in the frontal plane. Although posture is indi- and 60 degrees (approximate) to evaluate for the presence
vidualized, with a wide variation in what can be thought of a unilateral rib hump over the thoracic or lumbar spine.
of as “normal posture” among individuals, an “ideal” As a result of the rotation associated with lateral flexion of
posture in the sagittal plane has been described (Davies & the spine characteristic in scoliosis, asymmetric rib pro-
DeCarlo, 1995). This “ideal” lateral posture alignment has trusion exists and can be best identified by the clinician by
a plumb line traversing through the center or the external placing the patient in the Adam’s position and viewing the
auditory meatus (ear), mid-acromial bisection of the patient from a posterior position. Thorough evaluation of
scapula, greater trochanter of the femur, mid-lateral pelvic levels, as well as measurement of leg lengths, can
knee between the popliteal fossa and the patella, and just also assist in the postural evaluation of the patient with
anterior to the lateral malleolus. Significant deviations shoulder pathology presenting with associated postural
from this alignment should be noted and ultimately will conditions such as scoliosis. Table 3-1 lists additional pos-
affect the overall treatment of the patient with shoulder tural findings commonly encountered in patients with
pathology. shoulder pathology.
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CHAP TER

4 Testing the Scapulothoracic Joint

INTRODUCTION which it may obtain in one of several ways:” (1) the scap-
The importance of the scapulothoracic joint and its rela- ula may remain fixed with motion occurring solely at the
tionship to shoulder function and dysfunction have been glenohumeral joint until a stable position is reached, (2)
extensively reported by Kibler (1991, 1998a). Although the scapula moves laterally or medially on the chest wall,
this important relationship is well understood and widely or (3) in rare instances the scapula oscillates until stabi-
accepted, there are limited clinical tests to evaluate scapu- lization is achieved. After 30 degrees of abduction and 60
lothoracic function. Also, scapular position and move- degrees of flexion have been reached, the relationship of
ment have been most effectively documented in scapulothoracic to glenohumeral joint motion remains
experimental research conditions and not in the clinical remarkably constant.
setting (Lukasiewicz et al, 1999). Research using three-dimensional analysis and other
laboratory-based methods has confirmed Inman’s early
DESCRIPTION OF NORMAL SCAPULAR descriptions of scapulohumeral rhythm (Doody et al,
RESTING POSITION 1970; Bagg and Forrest, 1988). These studies have also
Although there are many variations in normal scapular provided more detailed descriptions of the exact contribu-
positioning, Kibler (2003) described resting scapular ori- tion of the scapulothoracic and glenohumeral joint during
entation as being 30 degrees anteriorly rotated with arm elevation in the scapular plane. Doody et al (1970)
respect to the frontal plane, as viewed from above. Also, found the ratio of glenohumeral to scapulothoracic
the scapula is rotated approximately 3 degrees upward motion to change from 7.29 : 1 in the first 30 degrees of
(superiorly), as viewed from the posterior orientation used elevation to 0.78 : 1 between 90 and 150 degrees. Bagg
during most clinical observations/examinations. Finally, and Forrest (1988) found similar differences based on the
the scapula is tilted anteriorly approximately 20 degrees range of motion. In the early phase of elevation,
when viewed from the direct lateral aspect of the body. 4.29 degrees of glenohumeral joint motion occurred for
every 1 degree of scapular motion, with 0.71 degrees of
OVERVIEW OF glenohumeral motion occurring for every 1 degree of
SCAPULOTHORACIC MOTION scapular motion between the functional arc of 80 and 140
Scapulothoracic movement was initially described in clin- degrees.
ical terms as “scapulo-humeral rhythm” by both Codman Bagg and Forrest (1988) also identified the instanta-
(1934) and Inman (1944). Inman stated that “the total neous center of rotation (ICR) of the scapulothoracic
range of scapular motion is not more than 60 degrees” and joint at various points in the range of motion. Figure 4-1
that the total contribution from the glenohumeral joint is shows the ICR of the scapulothoracic joint at 20 degrees
not greater than 120 degrees. The scapulohumeral rhythm of elevation and Figure 4-2 at approximately 140 degrees
was described for the total arc of elevation of the shoulder of elevation. The ICR moves from the medial border of
joint to contain 2 degrees of glenohumeral motion for the spine of the scapula, with the shoulder at approxi-
every degree of scapulothoracic motion (Inman et al, mately 20 degrees of elevation near the side of the body,
1944). and migrates superolaterally to the region near the
In addition to this ratio of movement, Inman et al acromioclavicular joint at approximately 140 degrees.
(1944) identified a “setting phase,” which occurred during Bagg and Forrest also identified an increased muscular
the first 30 to 60 degrees of shoulder elevation. They stabilization role of the lower trapezius and serratus ante-
described this setting phase as when “the scapula seeks, in rior force couple at higher, more functional positions of
relationship to the humerus, a precise position of stability elevation. Figures 4-1 and 4-2 also show the line of pull of

17
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18 SECTION I General Overview

Upper rhythm and identifying unilateral alterations in normal

trapezius scapular positioning are crucial in the complete evaluation
of the patient with shoulder pathology (Kibler, 1991,
1998a).
Middle
trapezius Deltoid
OVERVIEW AND DESCRIPTION OF
SCAPULAR MOTION
Typical movement of the scapula occurs in the coronal,
sagittal, and transverse planes. Brief descriptions here
20.8°
provide a framework for the classification of scapular
dysfunction and scapulothoracic joint testing sections pre-
sented later.
Lower
Lower serratus Upward/Downward Rotation
trapezius anterior
Movements of upward and downward rotation occur in
Figure 4-1 A biomechanical model of scapular rotation at 20.8 the coronal or frontal plane. The angle typically used to
degrees of abduction. Note the position of the instantaneous cen- describe the position of scapular rotation is formed
ter of rotation ICR and relative lengths of the lever arms of the between the spine and medial border of the scapula
scapular musculature. (Adapted from Bagg SD, Forrest WJ: A
(Figure 4-3). Poppen and Walker (1978) reported normal
biomechanical analysis of scapular rotation during arm abduction
in the scapular plane, Arch Phys Med Rehabil 67:243, 1988.) elevation of the acromion at approximately 36 degrees
from the neutral position to maximum abduction.
Upper Deltoid
trapezius
Anterior/Posterior Tilting
Sagittal plane motion of the scapula is referred to as ante-
rior/posterior tilting (see Figure 4-3). The angle of scapu-
lar tilting is formed by a vector passing via C7 and T7 and
Middle a vector passing via the inferior angle of the scapula
trapezius and the root of the spine of the scapula (Lukasiewicz
139.1° et al, 1999).

Internal/External Rotation
Transverse plane movement of the scapula is referred to as
internal and external rotation (see Figure 4-3). The angle
47.7°
used to describe internal/external rotation of the scapula is
formed by the coronal (frontal) plane of the body and a
Lower
Lower serratus vector passing via the transverse plane projection of the
trapezius anterior root of the spine of the scapula and the posterior angle of
the scapula (Lukasiewicz et al, 1999). Abnormal increases
Figure 4-2 A biomechanical model of scapular rotation at 139.1
degrees of abduction. Note the position of the instantaneous cen- in the internal rotation angle of the scapula lead to
ter of rotation ICR and relative lengths of the lever arms of the changes in the orientation of the glenoid. This altered
scapular musculature. (Adapted from Bagg SD, Forrest WJ: A position of the glenoid is referred to as “antetilting,” and it
biomechanical analysis of scapular rotation during arm abduction allows for an opening up of the anterior half of the gleno-
in the scapular plane, Arch Phys Med Rehabil 67:243, 1988.)
humeral articulation (Kibler, 1991). The antetilting of the
scapula has been shown by Saha (1983) to be a compo-
the serratus anterior and trapezius muscles and the relative nent of the subluxation/dislocation complex in patients
changes in the lever arm of each muscle in the two posi- with microtrauma-induced glenohumeral instability.
tions of glenohumeral joint elevation. This biomechanical
information on the scapulothoracic joint is presented in Protraction/Retraction
this text as a precursor to the important evaluation meth- The movement of retraction and protraction occurs liter-
ods and scapular dysfunction classification in the next ally around the curvature of the thoracic wall (Kibler,
section. Evaluating scapular position and scapulohumeral 1998a). Retraction typically occurs in a curvilinear fashion
Ch04.qxd 5/24/04 4:28 PM Page 19

CHAPTER 4 Testing the Scapulothoracic Joint 19

often identifies excessive early scapular elevation as a

compensatory movement to optimize humeral movement
C7 (Kibler, 1998a).

CLASSIFICATION OF
SCAPULAR DYSFUNCTION
Before discussing specific tests for the scapulothoracic
T7 joint, it is appropriate to describe types of scapulothoracic
pathology that can be identified by examination
maneuvers.
The most widely described and overused term pertain-
A ing to scapular pathology is that of scapular winging.
C7
Scapular winging is used to describe gross dissociation of
the scapula from the thoracic wall (Zeier, 1973). It is typi-
cally obvious to a trained observer when simply viewing a
patient from the posterior and lateral orientation and
becomes even more pronounced with active or resistive
X T7
movements to the upper extremities. True scapular wing-
B ing occurs secondary to involvement of the long thoracic
C nerve (Zeier, 1973). Isolated paralysis of the serratus ante-
rior muscle with resultant “winged scapula” was first
Figure 4-3 Definition of scapular position and orientation. described by Velpeau in 1837. The cause of winged scapu-
A, Upward rotation angle. The scapulothoracic angle is between
the medial border of the scapula (projected onto the frontal
la is peripheral in origin and is ultimately derived from
plane). Increasing values represent upward rotation. Total arm involvement of the fifth, sixth, and seventh spinal cord seg-
elevation is the angle between the spine and vector connecting ments (Zeier, 1973). Isolated serratus anterior muscle
the olecranon and a derived point 2 cm directly inferior to the pos- weakness as a result of nerve palsy creates a prominent
terior angle of the acromion. B, Scapular internal rotation angle. superior medial border of the scapula and depressed
The angle between the frontal plane and a vector passing through
the root of the spine of the scapula posterior angle of the
acromion, whereas isolated trapezius muscle weakness
acromion (projected onto the transverse lane). Increasing values resulting from nerve palsy creates a protracted inferior bor-
represent internal rotation. C, Scapular posterior tilt angle. The der of the scapula and elevated acromion (Kibler, 1998).
angle between a vector passing through C7 and T7 and a vector Although it is possible that some patients with shoul-
passing through the inferior angle and the spine of the scapula der pathology may present with true scapular winging,
(projected onto the sagittal plane). Increasing values represent
posterior tilting. C7, Seventh cervical process; T7, seventh tho-
most present with less obvious and less severe forms of
racic spinous process. (Adapted from Lukasiewicz AC et al: Com- scapular dysfunction. Clinicians have traditionally had
parison of 3-dimensional scapular position and orientation little nomenclature or objective descriptions for scapular
between subjects with and without shoulder impingement, J dysfunction, which has led to the use of numerous terms
Orthop Sports Phys Ther 29(10):578, 1999.) to describe nonoptimal or abnormal scapular positions
and movement patterns (Kibler, 1998a).
around the wall, whereas protraction may proceed in a
slightly upward or downward motion, depending on the Kibler Scapular Dysfunction Classification
position of the humerus relative to the scapula (Kibler, Rubin and Kibler (2002) classified scapular dysfunction
1998a). Depending on the size of the individual and the into two main types. When scapular dysfunction occurs
vigorousness of the activity, the translation of the human proximal and posterior to the glenohumeral joint, the
scapula during protraction and retraction can occur over observed scapular dyskinesis is considered proximally
distances of 15 to 18 cm (Kibler, 1993). derived and has been termed proximally derived scapular
dysfunction (PDSD). PDSD is commonly associated with
Elevation/Depression postural dysfunction such as forward head posture and
The scapula can move in the coronal plane along the lumbopelvic weakness, as well as injury to the long
thoracic wall superiorly and inferiorly in movements thoracic nerve or spinal accessory nerve, which leads to
typically called elevation and depression, respectively. weakness of the serratus anterior and upper trapezius,
Evaluation of the patient with rotator cuff weakness respectively. When any of these types of pathology exist or
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