Journal of Bodywork & Movement Therapies (2017) 21, 386e400

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REVIEW: SYSTEMATIC REVIEW

The role of scapular kinematics in patients

with different shoulder musculoskeletal
disorders: A systematic review approach
Roshanak Keshavarz, PT, MSc, DPT a,
Siamak Bashardoust Tajali, PT, MSc, PhD a,*,
Seyed Mohsen Mir, PT, MSc, PhD a,
H. Ashrafi, MSc, PhD b

a
Department of Physical Therapy, School of Rehabilitation, Tehran University of Medical Sciences,
Tehran, Iran
b
Department of Applied Design, Faculty of Mechanical Engineering, University of Kashan, Kashan, Iran

Received 11 May 2016; received in revised form 10 August 2016; accepted 2 September 2016

KEYWORDS Summary This study aimed to identify the role of the scapula in shoulder musculoskeletal
Scapular Kinematics; disorders (SMDs) and provided a systematic review of available studies in the field of scapular
Shoulder three-dimensional kinematics. We systematically searched 5 international databases,
Musculoskeletal including Scopus, EMBASE, PubMed, CINAHL, PEDro, and Cochrane Library from June to
Disorders; September 2015. Twenty studies met the inclusion criteria and were retrieved in full paper.
Scapulothoracic The selected studies were critically appraised independently by two researchers. The patients
Muscles; with shoulder impingement syndrome (SIS) and shoulder instability had an increased protrac-
Shoulder; tion, lesser upward rotation (UR), and increased internal rotation (IR) during scapular plane
Pain; elevation, whereas the patients with frozen shoulders had lesser protraction. Moreover, the
Disability patients with SIS had a greater scapular posterior tilt (PT) and external rotation during shoul-
der abduction. Increased scapular UR and PT with decreased scapular IR was seen in patients
with stiffness of Latissimus Dorsi and fibromyalgia without any changes in the scapular IR.
The results of this systematic review help the clinicians to have an insight about scapular
kinematics as a predictive index for SMDs.
2016 Elsevier Ltd. All rights reserved.

* Corresponding author. Fax: 98 21 77533939.

E-mail address: s_bashardoust@yahoo.com (S. Bashardoust Tajali).

http://dx.doi.org/10.1016/j.jbmt.2016.09.002
1360-8592/ 2016 Elsevier Ltd. All rights reserved.
The role of scapular kinematics in patients with different shoulder musculoskeletal disorders
Introduction
Shoulder pain is one of most common musculoskeletal com-
plaints in modern societies. Up to 40% of the population ex-
periences shoulder pain in their life which includes 20.9% of
musculoskeletal disorders (SMDs) in the general population
(Lawrence et al., 2014). Proper scapula position and orien-
tation are necessary for improving shoulder strength, stabil-
ity, range of motion, and premium functional ability (Kibler
et al., 2006). Through recent decades, researchers have
focused on the role of scapular control in SMDs (Ludewig and
Reynolds, 2009). The scapula is a key link between the upper
extremity and axial skeleton during daily activities. The
muscles attached to the scapula provide proximal stability for
the upper extremity activities (Kibler and McMullen, 2003).
When the scapular musculature cannot stabilize the scapula,
neuromuscular performances might be affected leading to
shoulder malfunction (Voight and Thomson, 2000).
Numerous studies have found that scapulothoracic mo-
tions are different between patients with various SMDs and
asymptomatic individuals (De Baets et al., 2013; Timmons
et al., 2012). Scapular dyskinesis has been found in 32% of
the patients with shoulder instability (SI) and 57% of the
patients with shoulder impingement syndrome (SIS)
(Warner et al., 1992). Furthermore, these comparisons
were provided using surface electromagnetic sensors.
However, skin-motion artifacts related to surface electro-
magnetic sensors may create the differences among the
groups (Hamming et al., 2012; Karduna et al., 2001).
There is a clear controversy in SMD studies which have re-
ported scapular-kinematics alterations in patients with the
SMDs. The main role of scapular kinematics in the upper ex-
tremity function helps the practitioners to recover the scapular
pattern movement for all shoulder dysfunctions and/or pa-
thologies. Our systematic review study helps the clinicians to
have an insight about scapular kinematics as a predictive index
for SMDs (Green et al., 2013; Ludewig and Reynolds, 2009).
There is little evidence to provide systematic informa-
tion on scapular kinematics in specific shoulder pathologies
such as SIS (Timmons et al., 2012), stroke (De Baets et al.,
2013), SI (Struyf et al., 2011), and unimpaired shoulders
(Borsa et al., 2003). We aimed to present a systematic
method to summarize the results of studies on different
types of shoulder disorders in the field of scapular kine-
matics. The aim of this systematic review was to identify
abnormal kinematic patterns and their role in the diagnosis
of SMDs based on scapular kinematics. We searched for
scapular kinematics alterations from the normal pattern in
various types of musculoskeletal shoulder disorders. The
hypothesis of our study was abnormal kinematics might
have a considerable role in different types of SMDs
(Ludewig and Reynolds, 2009). This study may help the
clinicians with the diagnosis of SMDs type and/or abnormal
scapular kinematics as a simple guide.
Method
Eligibility criteria
We included published studies in English language to
compare scapular kinematics in five groups of the most
387
common SMDs (SIS, Frozen Shoulder (FS), SI, Rotator Cuff
Tear (RCT) and Scapulothoracic Muscles Problems (STMPs)).
The inclusion criteria were professional and clinical
confirmation of the SMD by various clinical examinations,
and the use of a motion analyzer and similar kinematic
methods (Euler angle) to calculate 3-D scapular kinematics,
during the active humerothoracic elevation as clearly
stated in the paper. Three scapular kinematic variables
(scapular upward rotation, external rotation, and posterior
tilt) were present in the included papers. Differences be-
tween five mentioned SMDs and controls was not be
accredited to the kinematic motion-capture methods.
The studies were excluded if they were not published in
English language. Studies conducted on non-specific shoul-
der pain, non-adult age groups, animals, cadaver, as well as
single-subject case reports were excluded.
Search strategy
We searched the Cochrane Database Library, MEDLINE
(1968e2014), EMBASE, CINAHL (1974e2014), PubMed, Sco-
pus, and PEDro from June to September 2015 using MeSH
and indexing terms. The full search strategy is depicted in
Fig. 1. We also searched the ProQuest and SIGLE from June
to September 2015 to find the unpublished and/or gray
literature. Reference lists of systematic reviews were
searched to find more related studies. Excluded studies and
their reasons for exclusion are listed in Index 1.
Study selection
Two investigators (RK and SBT) searched and assessed all
distinguished titles and abstracts to identify the studies.
The full text of the eligible studies was retrieved and
reviewed independently by two researchers (RK and SBT).
The data were extracted separately by the researchers. In
case of any disagreement, the researchers reached a
consensus by exchanging ideas.
The studies were also excluded if the subjects had a
history of shoulder surgery or dislocation and shoulder-
girdle fracture or shoulder pain produced by neck motion.
The use of 3-D scapular kinematics during reaching or
grasping tasks also resulted in the exclusion of the study.
Each selected study was screened and entered into a
data extraction form by two investigators independently
(RK and SBT). All data, including the authors names,
publication date, characteristics of the study population,
sample size, diagnosis, age, gender, dominant hand, and
the kinematic measurement method, were entered into
tables (Table 1). Scapular kinematics measurement
methods included task, motion capture system, scapular
kinematic techniques, Euler decomposition, scapular
landmark, and range of humerothoracic elevation (Table 2).
In general, there were twenty studies that reported 3-D
scapular kinematics in patients with the SMDs (Tables 1 and
2). Eleven studies provided a comparison between healthy
participants and patients with SIS, and six studies reviewed
RCTs, FS, and SMPTs systematically. Three studies stated
the differences in scapular kinematics between healthy
people and patients with SI.
388
Figure 1 Search strategy and summery of the literature search.
Assessment of quality
The quality of the included studies was critically appraised
individually by two researchers (RK and SBT). The checklists
such as the CASP tool (www.casp-uk.net) (Singh, 2013),
STROBE Statement (Von Elm et al., 2007), and STARD
(Bossuyt et al., 2003) did not validate to assess the quality
of observational studies. None of the CASP tools were
appropriate for your purpose and therefore you created
your own quality measure based on the questions in the
CASP and STARD tools, and do not mention case control
studies or qualitative studies. Seven different criteria were
R. Keshavarz et al.
selected to evaluate the related methodological subjects
based on our research method. The scoring tool of the
included studies could predict the following criteria: 1.
inclusion/exclusion criteria, 2. manner of case selection, 3.
definition of scapular rotations, 4. methods of task per-
formance, including sensor and electrode placement, 5.
reliability of the applied methodology, 6. statistical power
(justification of sample size), and 7. statistical procedure
(Table 3) (De Baets et al., 2013).
The results of our research could provide an analysis of
the data and the methodological quality of the included
studies (Table 5). The Cochrane Collaboration tool was used
The role of scapular kinematics in patients with different shoulder musculoskeletal disorders 389

Table 1 Description of the study population for the selected papers on scapular kinematics.
Study Subjects (n) Age (year) Gender Dominant side
Con. Exp. Con. Exp. Control Exp. Control Exp.
F M F M R L R L
A: SIS Group
Lukasiewicz et al. (1999) 20 37 34.3  7.5 45.8  11.0 12 8 8 12 20 e 32 5
Ludewig and Cook (2000) 26 26 20e71 Range 25e68 Range e 26 e 26 e
Borstad and Ludewig (2002) 26 26 20e71 Range 25e68 Range e 26 e 26 e
Hebert et al. (2002) 10 41 34.4  8.4 44.3  9.2 6 4 20 21 5 5 33 8
Laudner et al. (2006) 11 11 21.2  1.7 22.1  3.5 e 11 e 11 e
McClure et al. (2006) 45 45 26e74 Range 24e74 Range 21 24 21 24 38 7 38 7
Roy et al. (2007) 15 8 37.3 46.1 8 7 7 1 15 e 5 3
Seitz et al. (2012) 21 23, 2 drops 18e70 Range 18e70 Range 11 10 10 11 e
Lawrence et al. (2014) 12 12, 2 drops 29.3 35.7 5 7 5 5 11 1 10 e
Haik et al. (2014b) 23 26 27.7  6.84 29.65  9.09 e 7 D, 16 N 16 D, 10 N
Lopes et al. (2015) 19 19 46.4  10.9 40.2  13.8 8 11 7 12 e
B: RCT Group
Mell et al. (2005) 15 27 30e74 Range 30e74 Range 9 6 7 20 e
de Oliveira Sousa et al. (2014) 26 48 Control: 45.81  8.68 13 13 10 28 e
ACO: 42.78  11.74
ACO RCD: 48.16  8.69
C: FS Group
Rundquist et al. (2003) 10 10 51  10.55 52.9  10.49 9 25 9 1 e 4 6
Fayad et al. (2008) e 16 OA, 16 FS e OA: 56e86 e e 25 7 e OA: 9 2
FS: 41-69 5 bilat 6
FS: 10
D: SI Group
Ogston and Ludewig (2007) 29 29, 4 drops 16e45 15e43 13 16 13 16 28 1 24 1
Illyes and Kiss (2006) 15 15 26.35  5.61 21.85  3.8 5 10 5 10 e
Matias and Pascoal (2006) e 3 ASI, 2 MDI 1 SI e 37  8.5 e 3 3 e
E: STMPs Group
Laudner and Williams (2013) 19 swimmers with no e 18.8  0.9 e 12 7 e
recent upper extremity
pathology
Avila et al. (2014) 25 40 47.2  5.3 48.3  8.8 25 0 40 0 e
SIS: Shoulder Impingement Syndrome; RCT: Rotator Cuff Tear; CRCT: Chronic Rotator Cuff Tendinopathy; FT-RCTs: Full Thickness Rotator
Cuff Tears; FS: Frozen Shoulder; OA: Osteoarthritis; SI: Shoulder Instability; MDI: Multidirectional Instability; ASI: Anterior Shoulder
Instability; STMDs: Scapulothoracic Muscular problems; FM: Fibromyalgia; F: Female; M: Male; R: Right; L: Left; D: Dominant side; N:
Non-dominant side.

to assess the risk of biases (selection, performance,
detection, attrition and/or reporting biases). All sub-
headings of Cochrane Collaboration tool are not suitable for
assessing the risk of bias in observational studies (Table 4)
(Hurlow et al., 2012). Therefore, the quality and integrity
of the study outcomes were assured.
Results
Study characteristics
Twenty studies met inclusion criteria and were retrieved in
full text out of 669 potential abstracts in field of SMDs. All
the included studies had a comparative observational or
case-control design (Fig. 1). Not all studies reported the
examiners risk of biases, and some researchers did not
report their method of blinding and/or concealment allo-
cation. The participants in both case and control groups
were age-matched in all included studies (in a range of
18e70 years, not children). Arm elevation was done in
three movement planes (frontal, sagittal, and scapular);
however, all included studies did not report alteration of
scapular kinematics in three movement planes and two
phases (elevation and lowering). Most of the included
studies reported scapular kinematics differences in one or
two arm movement planes (sagittal, frontal, or scapular
plane) during the elevation phase.
390 R. Keshavarz et al.

Table 2 Brief details of task and measurement methods of included papers on scapular kinematics in shoulder musculo-
skeletal disorders.
Study Task Motion Scapular kinematics Euler Scapular HT
capture measuring technique decomposition Landmark elevation
system
A: SIS Group
Lukasiewicz et al. (1999) Static Sc Emag Static digitizer Pro/lat/tilt TS, AA, AI 90
Ludewig and Cook (2000) Sc Emag Acromial receiver e Skin Pro/lat/tilt TS, AC, AI 30 120 ;
fixed E, L
Borstad and Ludewig (2002) Sc Emag Acromial receiver e Skin Pro/lat/tilt TS, AC, AI 40 120
fixed
Hebert et al. (2002) F, S 3D optical NR Lat/tilt/pro NR 110
Laudner et al. (2006) Sc Emag Acromial receiver e Skin Pro/lat/tilt TS, AA, AC, AI 0 120
fixed
McClure et al. (2006) S, Sc Emag Scapular receiver-Skin Pro/lat/tilt NR 40 120
fixed
Roy et al. (2007) Static F, S 3D optical Acromial receiver- Flexible Pro/lat/tilt TS, AC, AI Flex. 70
template Abd. 90
Seitz et al. (2012) Static Sc Emag Acromial receiver e Skin Pro/lat/tilt AA 90
fixed
Lawrence et al. (2014) F, S, Sc Emag Acromial receiver-Bone Pro/lat/tilt AA 30 e120
fixed
Haik et al. (2014b) S Emag Acromial receiver e Skin Pro/lat/tilt TS, AA, AI 30 e120 ,
fixed E,L
Lopes et al. (2015) F Emag Acromial receiver e Skin Pro/lat/tilt TS, AA, AI 30 e120
fixed
B: RCT Group
Mell et al. (2005) S, Sc Emag Scapular receiver-Skin Pro/lat/tilt TS, AC, AI 0 e100
fixed
de Oliveira Sousa et al. (2014) F, S Emag Acromial receiver e Skin Pro/lat/tilt TS, AA, AI 30 e120 ,
fixed E,L
C: FS Group
Rundquist et al. (2003) F, S, SC, Emag Acromial receiver e Skin Pro/lat/tilt TS, AA, AI Full range
IR, ER fixed
Fayad et al. (2008) F, S Emag Acromial receiver e Skin Pro/lat/tilt TS, AA, AI 30 e60
fixed
D: SI Group
Ogston and Ludewig (2007) F, Sc Emag Acromial receiver e Skin Pro/lat/tilt TS, AC, AI 0 e120
fixed
Illyes and Kiss (2006) Sc US motion Triplet on scapula-Skin NR TS, AA, AI 100 e120
analysis fixed
Matias and Pascoal (2006) S Emag Scapular receiver-Manually Pro/lat/tilt NR 120
positioned
E: STMPs Group
Laudner and Williams (2013) Sc Emag Acromial receiver- Skin Pro/lat/tilt C7, AA, H, St 30 e110
fixed
Avila et al. (2014) S, Sc Emag Acromial receiver- Skin Pro/lat/tilt Acromion 30 e120 ,
fixed E, L
Emag.: Electromagnetic; US: Ultrasound based; F: Frontal plane elevation; S: Sagital plane elevation; Sc: Scapular plane elevation; Pro:
Scapular protraction; Lat: Scapular lateral rotation; Tilt: Scapular tilt; TS: Trigonum spina scapulae; AA: Angulus acromialis scapulae; AI:
Angulus inferior scapulae; AC: Posterior acromioclavicular joint; IR: Scapular internal rotation; ER: Scapular external rotation; St: Stylus;
H: Humerous; E: Elevation phase; L: Lowering phase; HT: Humerothoracic; NR: Not reported.
*Scapular rotation analyzed up to 120 of humerothoracic elevation.
The role of scapular kinematics in patients with different shoulder musculoskeletal disorders 391

Table 3 Methodology quality of the included scapular kinematics papers.

Study Inclusion- Manner of Methods Definition Reliability of Justification Statistical Final
exclusion recruitment for task of scapular methodology for sample procedures score
performance rotations size (max. 14)
A: SIS Group
Lukasiewicz et al. 2 2 2 2 2 0 2 12
(1999)
Ludewig and Cook 2 2 2 2 2 0 2 12
(2000)
Borstad and Ludewig 2 2 2 2 2 0 2 12
(2002)
Hebert et al. (2002) 2 2 1 1 0 0 2 8
Laudner et al. (2006) 2 2 2 2 2 0 2 12
McClure et al. (2006) 2 2 2 2 2 0 2 12
Roy et al. (2007) 1 2 2 2 2 0 2 11
Seitz et al. (2012) 2 2 2 2 2 0 2 12
Lawrence et al. 2 2 1 2 2 0 2 11
(2014)
Haik et al. (2014b) 2 2 2 2 2 0 2 12
Lopes et al. (2015) 2 2 2 2 2 2 2 14
B: RCT Group
Mell et al. (2005) 1 0 2 2 2 0 2 9
de Oliveira Sousa 2 2 2 2 0 0 2 10
et al. (2014)
C: FS Group
Rundquist et al. 1 2 2 2 0 0 2 9
(2003)
Fayad et al. (2008) 1 0 1 2 2 0 2 8
D: SI Group
Ogston and Ludewig 2 2 2 2 2 2 2 14
(2007)
Illyes and Kiss (2006) 2 2 2 2 0 0 1 9
Matias and Pascoal 1 0 1 0 0 0 2 4
(2006)
E: STMDs Group
Laudner and Williams 1 1 2 2 1 0 2 9
(2013)
Avila et al. (2014) 2 2 2 2 0 0 2 10
2: Good description; 1: Moderate description; 0: No description.

Scapular kinematics show any substantial differences in the scapular posterior

Many studies reported various results in scapular kinematics
in patients with SIS. Scapular internal rotation was
enhanced in SI patients and reduced in FS patient. Studies
on rotator cuff tears (RCTs) showed an increased scapular
upward rotation and posterior tilt to compensate gleno-
humeral movements. The patients with shoulder pain had a
restricted scapular upward rotation.
These studies described the effect of the SMDs on
scapular kinematics during elevation. The results of the
included scapular kinematics studies are shown in Table 5.
Two researchers compared the results of both affected and
non-affected sides. In general, the patients with SIS had
less scapular upward and external rotation, but did not
tilt compared with arm elevation in the scapular plane. In
addition, these patients showed a greater posterior tilt and
external rotation, and less upward and external rotation in
the scapular plane when they abducted the upper
extremity.
Many studies in the field of 3-D scapular kinematics in
patients with SIS represented lesser scapular posterior tilt
above 90 of arm elevation and lesser scapular upward
rotation at 30 e60 of arm elevation compared with
healthy people (Herberts et al., 1984; Karduna et al., 2001;
Lukasiewicz et al., 1999; McClure et al., 2006). Conversely,
Ludewig and Cook reported that increased upward rotation
and posterior tilt might have a compensatory role to
decrease painful scapular motion during arm elevation
392 R. Keshavarz et al.

Table 4 Critical bias of the included scapular kinematics papers.

Study Selection bias Performance Detection Attrition Reporting
Random Allocation bias bias bias bias
sequence concealment
A: SIS Group
Lukasiewicz et al. (1999) Low Unclear Low Low High High
Ludewig and Cook (2000) Unclear Unclear Low Unclear High High
Borstad and Ludewig (2002) Unclear Unclear Low Low High High
Hebert et al. (2002) Unclear Unclear Low Low High High
Laudner et al. (2006) Unclear Unclear Low Low High High
McClure et al. (2006) Low Unclear Low Low High High
Roy et al. (2007) Low Unclear Low High High High
Seitz et al. (2012) Unclear Unclear Low High High High
Lawrence et al. (2014) Unclear Low Low Low High High
Haik et al. (2014b) Low Low High High High High
Lopes et al. (2015) Unclear Unclear Low High High High
B: RCT Group
Mell et al. (2005) Unclear Unclear Low Low High High
de Oliveira Sousa et al. (2014) High Unclear Low Low High High
C: FS Group
Rundquist et al. (2003) Low Unclear Low Low High High
Fayad et al. (2008) Unclear Unclear Low Low High High
D: SI Group
Ogston and Ludewig (2007) Unclear Unclear Low High High High
Illyes and Kiss (2006) Unclear Unclear Low Low High High
Matias and Pascoal (2006) Unclear Unclear Low Low High High
E: STMPs Group
Laudner and Williams (2013) Low Low Low Low High High
Avila et al. (2014) Low Low Low Low High High
Low: Criteria for a judgment of YES; High: Criteria for the judgment of NO; Unclear: Criteria for the judgment of UNCLEAR (un-
certain risk of bias).

(Ludewig and Cook, 2000). Laudner et al. (2006) found that
a significant increase posterior tilt might happen during arm
elevation in the scapular plane (Laudner et al., 2006).
Another study reported that pain could create similar
compensatory patterns or an increase in scapular upward
rotation among healthy participants with experimental pain
induction (Wassinger et al., 2013). However, Hebert and his
coworkers did not find any differences between partici-
pants with and without SIS (Hebert et al., 2002).
The scapular elevation during arm elevation in the
scapular plane was observed in patients with RCTs
compared with healthy people and patients with tendinosis
but no differences were reported for posterior tilt and
protraction (Mell et al., 2005a). In patients with RCT, the
scapula moved more than the humerus during arm elevation
when compared with healthy individuals or patients with
tendinopathy (Mell et al., 2005b). Two studies evaluated 3-
D scapular kinematics in patients with FS and demonstrated
earlier increased scapular external rotation during arm
elevation in frontal, sagittal, and scapular planes. There
were no differences in scapular tilt between affected and
unaffected sides.
Three studies on 3-D scapula kinematics in SI patients
reported a decrease in scapular upward rotation during arm
elevation in scapular and frontal planes (Illyes and Kiss,
2006; Laudner et al., 2006; Matias and Pascoal, 2006).
Moreover, these studies showed an increased internal
rotation during scapular plane elevation with no differ-
ences in glenohumeral translations among patients with
multidirectional SI. The patients with SI had similar scap-
ular kinematic changes (Ogston and Ludewig, 2007).
Another study showed different results: increased scapular
retraction and posterior tilt with no changes in scapular
external rotation in the same subjects (Matias and Pascoal,
2006). The patients with SIS or SI had an increased pro-
traction, and patients with frozen shoulders showed a
decreased protraction. Finally, two studies in field of STMPs
evaluated the effect of the fibromyalgia syndrome and
Latissimus Dorsi muscle stiffness on 3-D scapular kine-
matics. Increased scapular upward rotation and posterior
tilt with decreased scapular internal rotation during arm
elevation was seen in patients with Latissimus Dorsi stiff-
ness and fibromyalgia without changes in scapular internal
rotation (Laudner and Williams, 2013).
The role of scapular kinematics in patients with different shoulder musculoskeletal disorders
Table 5 Outcome variables and results of included scapular kinematics papers.
Study
A: SIS Group
Lukasiewicz et al. (1999)
Ludewig and Cook (2000)
Borstad and Ludewig (2002)
Hebert et al. (2002)
Laudner et al. (2006)
McClure et al. (2006)
Roy et al. (2007)
Seitz et al. (2012)
Lawrence et al. (2014)
Haik et al. (2014b)
Lopes et al. (2015)
B: RCT Group
Mell et al. (2005)
de Oliveira Sousa et al. (2014)
393
Reliability (ICC) Sig differences
SISG compared to CG
ICC (3,1) Y PT & [ inf-sup position at 90 ;
0.88e0.99 [ PT, UR, Y IR, [sup & med position in SISG & CG During
scapular elevation.
ICC(2,1) Y UR at 60 arm elevation, but no differences at 90 or 120
0.93e0.98 elevation
Y PT & Y ER at 120 .
Under loaded, [ IR
*No difference in PT, at 60 & 90 elevation.
*No group  load interaction effect for UR, PT.
*Group difference did not effect on phase of motion for IR
e Y UR at 40 and 60 elevation and Y PT at 100 and 120
elevation during both elevation & lowering phases.
[ IR at 120 arm elevation during the lowering phase.
e 48.2%e51.3% of the scapular total ROM was provided by Y PT,
in flexion & 40.3%e42.4% of it was ER in abduction.
Y UR and ER while having [ PT, in flexion.
Y UR, ER, and PT, in abduction.
0.97 [ PT and clavicular elevation.
*No differences in UR, ER, & clavicular retraction.
ICC(3,k) [ UR & clavicular elevation in flexion.
0.90 [ PT & clavicular retraction in scapular-plane elevation.
Y ROM & force in all directions.
ICC between day [ UR in all positions, [ PT and ER at 70 flexion.
0.62e0.97; YPT and ER at 90 abduction.
ICC(3,1) [ PT at totally angles.
0.98e0.99 [ UR at rest & 45 of elevation & acromiohumeral distance at
45 & at 90 with SAT.
*SAT did not change normalized isometric strength.
*SISG & CG had no alterations in reaction to the SAT.
ICC (1,1) Y Sternoclavicular PR, irrespective of angle, phase, or plane of
Control: 0.83e0.98 shoulder motion.
SIS: 0.76e0.96 Y SC elevation at 30 of arm elevation in scapular plane.
Y UR at 30 and 60 of elevation in frontal and scapular plane.
*No sig. difference between groups in AC kinematics.
ICC (2,1) ICC during arm elevation in both groups in ranged of 0.92e0.99.
0.92e0.99 ICC during arm lowering in both groups in ranged of 0.54e0.88.
ICC (2,3) ICC for assessment of scapular orientation with the arms
Control: 0.58e0.88 relaxed at the side in both groups in ranged of 0.66e0.95.
SIS: 0.54e0.85 SEM in ranged of 3.37 e7.44 for both groups.
MDC increased from 7.81 to 17.27 at the higher arm elevation
angles.
ICC (ascending Phase) Y Penn shoulder function.
0.22e0.95 Y ER during elevation & lowering.
ICC (descending 12.0% higher upper trapezius EMG in 30 - 60 elevation.
Phase)
0.39e0.93
RCT compared to CG
SD for phases 1, 2, & 3 [ SHR in 25 e77 & 77 e129 during flexion & in 77 e129
were 0.0078 , scapular abduction.
0.0078 , & 0.014 , *No difference in rhythm slope between CG & tendinopathy
respectively. group.
*No difference in PT & protraction.
[ Scapula motion for each degree of arm elevation in 77 e120
[ elevated scapula in the initial two thirds of movement.
e ACO group: [ IR, [ UR & Y SC elevation and Y SC PR.
(continued on next page)
394 R. Keshavarz et al.

Table 5 (continued )
Study Reliability (ICC) Sig differences
ACO RCD group: [ UR than both other groups.
ACO RCD & ACO groups: Y SC retraction & [ PT.
C: FS Group FSG compared to CG
Rundquist et al. (2003) e Y Maximum ROM of arm elevation from flexion to scapular
plane abduction to coronal plane abduction.
[ ER ROM with the abducted arm than with the arm at the side.
YIR ROM in the abducted arm.
Fayad et al. (2008) 0.93e0.99 Y Protraction during elevation in the sagittal & scapula plane.
Y Protraction & [ SHR in FSG than GHOG during abduction no
flexion.
[ Scapular lat. rot. & SHR in both groups in each plane of
elevation.
*No difference in PT between affected and unaffected sides
and was not influenced by type of disease.
D: SI Group MDIG compared to CG
Ogston and Ludewig (2007) ICC (1,1) Y UR during arm elevation in scapular & frontal planes.
angular-dependent [ IR during scapular plane abduction.
variables: [ PT during 0 e60 scapular plane abduction & no difference in
0.89e0.99 abduction.
ICC (1,1) *No significant alterations in GH translations.
Ant./post. [Passive humeral ER ROM & [ passive IR of the complicated
Translation: shoulder.
0.83e0.96 [ External passive ROM on the complicated side compared with
ICC (1,1) the uncomplicated side.
Sup./inf. Translation:
0.50e0.93
Illyes and Kiss (2006) e ST & GH rhythm of the affected shoulders are linear.
The ant, post, & inf. displacements of shoulders with MDI could
be modeled.
*Sig. difference in the displacement between the Rot. centers
of scapula & humerus, related to anthropometrical
differences.
Matias and Pascoal (2006) e The thorax slight extent & contra-lateral Rot around 90 of arm
elevation
[ retracted position in arm elevation above 90 .
[ PT near the 90 of arm elevation.
[ ER as arm elevation progress.
*Sig. differences in protraction on 3 subjects & in spinal tilt on
5 subjects.
*No differences in ER in all subjects.
E: STMPs Group Muscles problems compared to CG
Laudner and Williams (2013) ICC (2,3) Latissimus dorsi stiffness: [ UR & [ PT at all four angles of
0.92 humeral elevation.
[ Latissimus dorsi stiffness had moderate-to-good relationships
with Y IR at 60 & 90 of arm elevation.
Avila et al. (2014) e Fibromyalgia women: [ UR & [ PT than the control group.
No sig. in IR during arm elevation & lowering in the sagittal &
scapular planes.
SIS: Shoulder Impingement Syndrome; RCT: Rotator Cuff Tear; FS: Frozen Shoulder; SI: Shoulder Instability; MDI: Multidirectional
Instability; G: Group; CG: Control Group; Ant.: Anterior; Post.: Posterior; Scapular sup-inf: Scapular Superior Inferior; med-lat; Medial-
Lateral; UR: Upward Rotation; PT: Posterior Tipping; ER: External Rotation; IR: Internal Rotation; PR: Posterior Rotation; ROM: Range of
Motion; Rot: Rotation; SAT: Scapular Assistance Test; EMG: Electromyography; SHR: Scapulohumeral Rhythm; GH: Glenohumeral; ST:
Scapulothoracic; SC: Sternoclavicular; AC: Acromioclavicular; Sig.: Significant; SEM: Standard Error of Measurement; MDC: Standard
Error of Measurement; ICC: Intraclass correlation coefficient.
The role of scapular kinematics in patients with different shoulder musculoskeletal disorders
No significant differences were found between arm
elevation and lowering phases in the scapular plane, except
for scapular internal rotation at 120 and scapular anterior
tilt at higher humeral angles in patients with SIS. It should
be mentioned that differences in scapular internal rotation
and anterior tilt results in reduced accessible subacromial
space during arm elevation and lowering phases in the
scapular plane (Borstad and Ludewig, 2002; Seitz et al.,
2012).
Methodological aspects
The relevant papers were critically appraised by two re-
searchers independently based on the quality measure
method. The quality measure scores are briefly reported in
Tables 3 and 4. The Cochrane Collaboration tools for
assessing the risk of biases were in the range of moderate to
low for the included studies. This critical point shows that
all included studies did have degrees of bias (moderate to
high) (Table 5). The highest quality score (14/14) was for a
study conducted by Lopez et al. who justified the sample
size. However, a study by Haik et al. obtained the highest
quality in Cochrane Collaboration tools for doing perfor-
mance bias. The range of quality scores for RCT, FS and
STMPs studies was from 8 to 10. The methodological quality
showed that studies by Matias & Pascoal and also Ogston &
Ludwig gained the lowest score (4/14) and highest score in
SI studies, respectively. The rate of random sampling was
very low among the included studies; only one group of
researchers applied randomization for their RCT.
Thirteen studies reported intraclass correlation coeffi-
cient (ICC) ranging from excellent to good. The other seven
studies did not report the ICC values. Only one study was
designed for ICC evaluation of scapular kinematics in two
phases.
Discussion
Many researchers believe that scapular kinematics is an
important contributor for the level of pain and/or
disability in the shoulder joint (Fayad et al., 2008).
Appropriate scapular alignments and movements are
needed in order to achieve a normal function in the upper
extremities (Kibler and Sciascia, 2010). The most effective
position of the rotator cuff muscles is associated with
scapular alignments. Therefore, following SMDs, the pa-
tients may substantially benefit from an appropriate
rehabilitation program for restoration or correction of
scapular dyskinesia. The scapula does have a main role in
completing the shoulder ROM during abduction in com-
parison with flexion and scapular plane elevation (Kibler
and McMullen, 2003). As a result, abnormal scapular ki-
nematics may lead to SMDs (Ludewig and Reynolds, 2009).
This systematic review evaluated the scapular kinematics
among patients with shoulder musculoskeletal disorders
and speculated the altered scapular kinematics in various
types of shoulder disorders.
An important subacromial tissue injury model has
suggested that an alteration in thoracic spine alignment
(e.g. thoracic kyphosis, forward head posture,
395
intersegmental locking, or hypomobility of the upper
thoracic spine) is related to changes in the position of the
scapula, and an imbalance of the scapulothoracic mus-
cles. It is suggested that spinal alignment has a great in-
fluence on the scapular position and shoulder range of
motion (Lewis et al., 2005).
Several methodological aspects, i.e. various diseases,
joint angle calculation, measurement methods, proced-
ures, and tracking systems are required to be taken into
account for differences in scapular kinematics data of
various studies. The International Society of Biomechanics
suggests angulus acromialis (AA), trigonum spina (TS), and
angulus inferior (AI) to define the scapular joint coordina-
tion system to compare the 3-D kinematics results (Wu
et al., 2005). Recent studies have used the same mea-
surement protocols and tracking systems (motion analysis)
to compare 3-D scapular kinematic results among patients
with the SMDs.
Scapular kinematics in patients with shoulder
impingement syndrome
In patients with shoulder impingement, scapular upward
rotation was decreased at lower angles (30 e60 ) of arm
elevation in frontal and scapular planes, while other 3-D
scapular kinematics showed no significant changes
(Lawrence et al., 2014). These alterations may cause a
decline in the subacromial space and also the rotator cuff
tendinopathy. A slight drop of scapular posterior tilt of the
shoulders with SIS was associated with a complex disability
(Borstad and Ludewig, 2002; Endo et al., 2001; Lawrence
et al., 2014).
During arm elevation and lowering, scapular external
rotation was decreased in patients with SIS (Lopes et al.,
2015). Qualitative studies with lower methodology quality
scores suggest that in patients with SIS, scapular internal
rotation might increase during arm elevation (Hebert et al.,
2002; Ludewig and Cook, 2000). However, many high
quality studies did not find any substantial differences in
scapular ER/IR through arm elevation in patients with the
SIS and also healthy participants (Endo et al., 2001;
Lukasiewicz et al., 1999; McClure et al., 2006). The
reduced scapular external rotation may affect the sub-
acromial space, leading to shoulder pain and decreased
ROM of the SIS through arm elevation.
Scapular kinematics in patients with rotator cuff
tears
Age, gender, heavy work, dominant hand, and history of
trauma increased the probability of RCT. These patients
had a lower range in flexion and less power in abduction
and external rotation (Yamamoto et al., 2010). The rotator
cuff pathology had great effects on shoulder rhythm (slope
of the scapula/humeral elevation curve) during arm
elevation in scapular and sagittal planes. Mell et al.
(2005a,b) found that scapular elevation might increase
through all degrees of arm elevation in the scapular plane
both in healthy and the RCT groups. They also found no
396
differences in PT and protraction during arm elevation, but
not during flexion (Mell et al., 2005b).
Patients with full-thickness rotator cuff tear showed a
greater scapular elevation during arm elevation,
compared with the healthy individuals and/or patients
with tendinitis. This alteration of scapular kinematics
represented that RCT might be relevant to loss of cuff
strength and function rather than pain (Mell et al.,
2005a). The methodological quality score of two rele-
vant studies was moderate and both studies had a high
attrition bias score. As a result, there is no high quality
evidence to clarify abnormal scapular kinematics for pa-
tients with RCT.
Scapular kinematics in patients with frozen
shoulder
Studies in shoulder rhythm and scapular kinematics
demonstrated that scapular external rotation occurred
earlier and larger through arm elevation in frontal,
sagittal, and scapular planes as compared with the unaf-
fected shoulders and healthy participants. Moreover, the
scapular tilt was not substantially different between the
affected and unaffected sides (Rundquist et al., 2003;
Vermeulen et al., 2002). No strong evidence was avail-
able to support the common theory of the scapular
compensatory role in retrieving a maximal range of limited
glenohumeral joint through arm elevation (Fayad et al.,
2008). Yang believed that scapular kinematics might be a
predictor for the clinicians to assess patients with FS
although the etiology might be vague (Yang et al., 2008).
Looseness of glenohumeral mobility may lead to limita-
tions in external rotation of the humeral head and un-
derneath gliding of the acromion through arm elevation.
The capsular adhesions may lead to some degrees of lim-
itation. The scapula is pulled outwards prior to humerus
movement during elevation to reach the same end point of
the scapula and glenohumerus in healthy people. The
methodological quality of all included studies in FS pa-
tients was moderate.
Scapular kinematics in patients with shoulder
instability
The patients with SI represented a decrease in the scapular
upward rotation during arm elevation in scapular and
frontal planes, and also an increase in internal rotation
during scapular plane elevation. Our results confirmed the
results of studies by Ogston and also Ozaki that reported no
differences in glenohumeral translations among patients
with multidirectional SI (Ogston and Ludewig, 2007; Ozaki,
1989). Matias and Pascoal showed substantial alterations in
scapular protraction to retraction and also anterior to
posterior tilt in patients with the SI, while they did not find
any changes in scapular external rotation as compared with
healthy subjects (Matias and Pascoal, 2006). The patients
with SI had an increase in scapular upward rotation and a
slight scapular posterior tilt. There was no strong evidence
to confirm scapular kinematics alterations following SMDs.
R. Keshavarz et al.
Scapular kinematics in patients with
Scapulothoracic Muscles Problems
Among scapulothoracic muscles, stiffness of Latissimus
Dorsi had a moderate to good relationship with increased
scapular upward rotation and posterior tilt. Furthermore,
decreased scapular internal rotation during arm elevation
was seen in patients with STMPs (Laudner and Williams,
2013). It was reported that a stiff Latissimus Dorsi could
pull the inferior scapular border to more superior and
lateral, and caused an increase in upward rotation during
arm elevation. A stiff Latissimus Dorsi forces the scapula to
posterior tilt and external rotation because of the attach-
ments (Laudner and Williams, 2013). Regardless of the
specific origin, a different relationship has been shown
between Latissimus Dorsi stiffness and scapular dyskinesis.
The methodological quality score of both included studies
was moderate.
A similar increased scapular upward rotation and pos-
terior tilt was seen in fibromyalgia women during arm
elevation in sagittal and scapular planes (Avila et al.,
2014). The researchers reported that the scapulothoracic
muscles could affect scapular kinematics and behaviors
and cause different SMDs. Briefly, few studies found
various scapular muscle activity patterns in SMDs as
explained below:
In shoulder impingement, the upper and lower trapezius
and also the serratus anterior muscles have the key role in
scapular dyskinesis. The electromyographic activity of the
upper and lower trapezius muscles increases during arm
elevation. The serratus anterior muscle shows a decreased
activity in all phases (Lopes et al., 2015; Ludewig and Cook,
2000; Phadke and Ludewig, 2013).
It seems that in shoulders with glenohumeral instability,
the activity of the lower trapezius and serratus anterior
muscles might increase in the mid phase of arm elevation,
while muscle activity length of supraspinatus and infra-
spinatus is increased (Illyes and Kiss, 2006; Matias and
Pascoal, 2006).
Symptomatic patients with rotator cuff tear show a
trend toward increased muscle activation of supraspinatus,
infraspinatus and upper trapezius compared with asymp-
tomatic patients with rotator cuff tear. However, asymp-
tomatic subjects have a greater subscapularis activity
(Kelly et al., 2005).
The patients with frozen shoulder have an increased and
imbalanced upper and lower trapezius muscle activity
which may exchange the scapular movement to compen-
sate impaired glenohumeral motion. Greater scapular
elevation and upward rotation induce the compensatory
movement pattern (Fayad et al., 2008; Lin et al., 2005).
Our results showed that the patients with SMDs
compensated the impaired glenohumeral motion through
scapular substitution movement, excess scapular elevation,
and upward rotation during the elevation of their arm. The
increased application of accessory muscles such as trape-
zius activity may lead an abnormal scapular motion. These
results are in favor of clinical observations that suggest that
an abnormal scapular motion is noticeable in patients with
SMDs during arm elevation.
The role of scapular kinematics in patients with different shoulder musculoskeletal disorders 397

Study limitations Index (1). Characteristics of the excluded

studies.
The number of patients in many included studies was
limited. Individual specific variables, small sample sizes,
motion capture systems, different definitions for scapular
orientation, Euler decomposition, and inappropriate sta-
tistical methods might affect the results of the selected Study Reason to exclude
studies. Larger groups of patients might help our systematic SIS
review to better clarify the predictive role of the 3-D
scapular movement patterns in patients with SMDs. The Thomas et al. (2013) Use the inclinometer, healthy
assessment of healthy subjects and also patients with other population, only scapular UR
shoulder disorders may help to define alterations of scap- Su et al. (2004) Use the inclinometer, only
ular kinematics during arm elevation in frontal, sagittal, scapular UR
and scapular planes. Furthermore, the included studies did Graichen et al. (2001) Use MRI
not compare altered scapular kinematics in three shoulder Endo et al. (2001) Use X-ray
movement planes between symptomatic and asymptomatic Ackermann et al. (2002) Interventional trial, EMG study
patients. Finley et al. (2005) Manual wheel chair users
Ludewig and Braman Literature review
(2011)
Conclusions Williams et al. (2013) Interventional trial, healthy
population
There is a controversy in scapular kinematics among SIS Giphart et al. (2012) Healthy population, vivo
patients. Rotator cuff muscles have substantial effects on biplane fluoroscopy
scapular alignment and movement patterns. However, the Roy et al. (2010) Reaching task
evidence is still not enough to confirm different scapular Chopp et al. (2011) Fatigue protocol
kinematics in RCT (it was only reported by two moderate McClure et al. (2004) Interventional trial
quality studies). The patients with SI have a decreased Huang et al. (2013) Interventional trial
scapular UR and protraction as well as an increased scap- Worsley et al. (2013) Interventional trial
ular IR during scapular plane elevation. An earlier scapular Haik et al. (2014a) Interventional trial
ER is the only kinematic change during arm elevation in Hsu et al. (2009) Interventional trial
sagittal, frontal, and scapular planes in patients with FS. Kebaetse et al. (1999) Thoracic position effect on
Tightness of scapulothoracic muscles such as latissimus scapular kinematics
dorsi and serratus anterior may affect scapular dyskinesis Wang et al. (1999) Interventional trial
and induce SMDs. Wassinger et al. (2013) Use the inclinometer,
There is no clear causal relationship between scapular Subacromial pain induced
alteration and a specific pathology. Further researches are Nagai et al. (2013) Effects of truck rotation on the
necessary to determine the predictor index of scapular scapular kinematics
position and orientation changes in SMDs. Yoshizaki et al. (2009) Healthy population
Miachiro et al. (2014) Fatigue protocol
RCT
File copies permissions
Paletta et al. (1997) Use X-ray
Henseler et al. (2013) Use magnetic resonance
All of the tables and also the figure are original. There is no
imaging with arthrography
need for any permission.
Interventional trial, Thesis
Park et al. (2012) Literature review
Authors contributions McFarland et al. (2013) Case report
Kedgley et al. (2007) Study on cadaveric specimens
RK carried out the literature search and review, data Scibek et al. (2008) Interventional trial
extraction, prepared the initial draft, coordinated re- Muth et al. (2012) Interventional trial
visions, submitted the manuscript, and prepared the writ- Wilson et al. (2013) Unavailable full text, Use of
ten draft. SBT contributed to the literature search and Biplane fluoroscopic image
review, coordinated the appraisal, synthesized results, and Kijima et al. (2015) Use of Biplane fluoroscopic
contributed to data critical appraisal and manuscript re- image
visions. SMR and HA contributed to the search strategy and FS
revisions of the manuscript. All authors read and approved Braman et al. (2010) Case report
the final article. Fayad et al. (2008) No scapular 3-D kinematics
Roren et al. (2012) Activities of daily living
Shah et al. (2015) Diabetes mellitus population
Competing interests
Rundquist and Ludewig Idiopathic loss of shoulder
(2005) range of motion
The authors declare that they have no competing interests.
(continued on next page)
398
(continued )
Study Reason to exclude
SI
Paletta et al. (1997) Use X-ray
von Eisenhart-Rothe et al. Use MRI
(2005)
Baeyens et al. (2001) Use Helical CT
von Eisenhart-Rothe et al. Use MRI
(2002)
STMDs
Lucas et al. (2010) Electromyography study
Borstad and Ludewig (2005) Study on cadaveric specimens
References
Ackermann, B., Adams, R., Marshall, E., 2002. The effect of
scapula taping on electromyographic activity and musical per-
formance in professional violinists. Aust. J. Physiother. 48 (3),
197e203.
Avila, M.A., Camargo, P.R., Ribeiro, I.L., Zamuner, A.R.,
Salvini, T.F., 2014. Three-dimensional scapular motion during
arm elevation is altered in women with fibromyalgia. Clin.
Biomech. 29 (7), 815e821.
Baeyens, J.-P., Van Roy, P., De Schepper, A., Declercq, G.,
Clarijs, J.-P., 2001. Glenohumeral joint kinematics related to
minor anterior instability of the shoulder at the end of the late
preparatory phase of throwing. Clin. Biomech. 16 (9), 752e757.
Borsa, P.A., Timmons, M.K., Sauers, E.L., 2003. Scapular-posi-
tioning patterns during humeral elevation in unimpaired shoul-
ders. J. Athl. Train. 38 (1), 12.
Borstad, J.D., Ludewig, P.M., 2002. Comparison of scapular kine-
matics between elevation and lowering of the arm in the
scapular plane. Clin. Biomech. 17 (9), 650e659.
Borstad, J.D., Ludewig, P.M., 2005. The effect of long versus short
pectoralis minor resting length on scapular kinematics in
healthy individuals. J. Orthop. Sports Phys. Ther. 35 (4),
227e238.
Bossuyt, P.M., Reitsma, J.B., Bruns, D.E., Gatsonis, C.A.,
Glasziou, P.P., Irwig, L.M., Lijmer, J.G., 2003. The STARD
statement for reporting studies of diagnostic accuracy: expla-
nation and elaboration. Ann. Intern. Med. 138 (1), W1eW12.
Braman, J.P., Thomas, B.M., LaPrade, R.F., Phadke, V.,
Ludewig, P.M., 2010. Three-dimensional in vivo kinematics of an
osteoarthritic shoulder before and after total shoulder arthro-
plasty. Knee Surg. Sports Traumatol. Arthrosc. 18 (12),
1774e1778.
Chopp, J.N., Fischer, S.L., Dickerson, C.R., 2011. The specificity of
fatiguing protocols affects scapular orientation: implications for
subacromial impingement. Clin. Biomech. 26 (1), 40e45.
De Baets, L., Jaspers, E., Desloovere, K., Van Deun, S., 2013. A
systematic review of 3D scapular kinematics and muscle activity
during elevation in stroke subjects and controls. J. Electro-
myogr. Kinesiol. 23 (1), 3e13.
Endo, K., Ikata, T., Katoh, S., Takeda, Y., 2001. Radiographic
assessment of scapular rotational tilt in chronic shoulder
impingement syndrome. J. Orthop. Sci. 6 (1), 3e10.
Fayad, F., Roby-Brami, A., Yazbeck, C., Hanneton, S., Lefevre-
Colau, M.-M., Gautheron, V., Revel, M., 2008. Three-dimen-
sional scapular kinematics and scapulohumeral rhythm in pa-
tients with glenohumeral osteoarthritis or frozen shoulder. J.
Biomech. 41 (2), 326e332.
R. Keshavarz et al.
Finley, M.A., McQuade, K.J., Rodgers, M.M., 2005. Scapular ki-
nematics during transfers in manual wheelchair users with
and without shoulder impingement. Clin. Biomech. 20 (1),
32e40.
Giphart, J.E., van der Meijden, O.A., Millett, P.J., 2012. The ef-
fects of arm elevation on the 3-dimensional acromiohumeral
distance: a biplane fluoroscopy study with normative data. J.
Shoulder Elb. Surg. 21 (11), 1593e1600.
Graichen, H., Stammberger, T., Bonel, H., Wiedemann, E.,
Englmeier, K.H., Reiser, M., Eckstein, F., 2001. Three-dimen-
sional analysis of shoulder girdle and supraspinatus motion
patterns in patients with impingement syndrome. J. Orthop.
Res. 19 (6), 1192e1198.
Green, R.A., Taylor, N.F., Watson, L., Ardern, C., 2013. Altered
scapula position in elite young cricketers with shoulder prob-
lems. J. Sci. Med. Sport 16 (1), 22e27.
Haik, M.N., Alburquerque-Sendn, F., Silva, C.Z., Siqueira-
Junior, A.L., Ribeiro, I.L., Camargo, P.R., 2014a. Scapular ki-
nematics preeand postethoracic thrust manipulation in in-
dividuals with and without shoulder impingement symptoms: a
randomized controlled study. J. Orthop. Sports Phys. Ther. 44
(7), 475e487.
Haik, M.N., Alburquerque-Sendn, F., Camargo, P.R., 2014b. Reli-
ability and minimal detectable change of 3-dimensional scap-
ular orientation in individuals with and without shoulder
impingement. J. Orthop. Sports Phys. Ther. 44 (5), 341e349.
Hamming, D., Braman, J.P., Phadke, V., LaPrade, R.F.,
Ludewig, P.M., 2012. The accuracy of measuring glenohumeral
motion with a surface humeral cuff. J. Biomech. 45 (7),
1161e1168.
Hebert, L.J., Moffet, H., McFadyen, B.J., Dionne, C.E., 2002.
Scapular behavior in shoulder impingement syndrome. Archives
Phys. Med. Rehabil. 83 (1), 60e69.
Henseler, J., Nagels, J., van der Zwaal, P., Nelissen, R., 2013. Teres
major tendon transfer for patients with massive irreparable
posterosuperior rotator cuff tears Short-term clinical results.
Bone Jt. J. 95 (4), 523e529.
Herberts, P., Kadefors, R., Hogfors, C., Sigholm, G., 1984. Shoulder
pain and heavy manual labor. Clin. Orthop. Relat. Res. 191,
166e178.
Hsu, Y.-H., Chen, W.-Y., Lin, H.-C., Wang, W.T., Shih, Y.-F., 2009.
The effects of taping on scapular kinematics and muscle per-
formance in baseball players with shoulder impingement syn-
drome. J. Electromyogr. Kinesiol. 19 (6), 1092e1099.
Huang, H.-Y., Lin, J.-J., Guo, Y.L., Wang, W.T.-J., Chen, Y.-J.,
2013. EMG biofeedback effectiveness to alter muscle activity
pattern and scapular kinematics in subjects with and without
shoulder impingement. J. Electromyogr. Kinesiol. 23 (1),
267e274.
Hurlow, A., Bennett, M.I., Robb, K.A., Johnson, M.I., Simpson, K.H.,
Oxberry, S.G., 2012. Transcutaneous electric nerve stimulation
(TENS) for cancer pain in adults. Cochrane Database of System-
atic Reviews (3). Art. No.: CD006276. DOI: http://dx.doi.org/10.
1002/14651858.CD006276.pub3.
Illyes, A., Kiss, R.M., 2006. Kinematic and muscle activity charac-
teristics of multidirectional shoulder joint instability during
elevation. Knee Surg. Sports Traumatol. Arthrosc. 14 (7),
673e685.
Karduna, A.R., McClure, P.W., Michener, L.A., Sennett, B., 2001.
Dynamic measurements of three-dimensional scapular kine-
matics: a validation study. J. Biomech. Eng. 123 (2), 184e190.
Kebaetse, M., McClure, P., Pratt, N.A., 1999. Thoracic position
effect on shoulder range of motion, strength, and three-
dimensional scapular kinematics. Archives Phys. Med. Rehabil.
80 (8), 945e950.
Kedgley, A.E., Mackenzie, G.A., Ferreira, L.M., Johnson, J.A.,
Faber, K.J., 2007. In vitro kinematics of the shoulder following
rotator cuff injury. Clin. Biomech. 22 (10), 1068e1073.
The role of scapular kinematics in patients with different shoulder musculoskeletal disorders
Kelly, B.T., Williams, R.J., Cordasco, F.A., Backus, S.I., Otis, J.C.,
Weiland, D.E., Warren, R.F., 2005. Differential patterns of
muscle activation in patients with symptomatic and asymp-
tomatic rotator cuff tears. J. Shoulder Elb. Surg. 14 (2),
165e171.
Kibler, B.W., McMullen, J., 2003. Scapular dyskinesis and its rela-
tion to shoulder pain. J. Am. Acad. Orthop. Surg. 11 (2),
142e151.
Kibler, W.B., Sciascia, A., 2010. Current concepts: scapular dyski-
nesis. Br. J. Sports Med. 44 (5), 300e305.
Kibler, W.B., Sciascia, A., Dome, D., 2006. Evaluation of apparent
and absolute supraspinatus strength in patients with shoulder
injury using the scapular retraction test. Am. J. Sports Med. 34
(10), 1643e1647.
Kijima, T., Matsuki, K., Ochiai, N., Yamaguchi, T., Sasaki, Y.,
Hashimoto, E., Yamaguchi, S., 2015. In vivo 3-dimensional
analysis of scapular and glenohumeral kinematics: comparison
of symptomatic or asymptomatic shoulders with rotator cuff
tears and healthy shoulders. J. Shoulder Elb. Surg. 24 (11),
1817e1826.
Laudner, K.G., Myers, J.B., Pasquale, M.R., Bradley, J.P.,
Lephart, S.M., 2006. Scapular dysfunction in throwers with
pathologic internal impingement. J. Orthop. Sports Phys. Ther.
36 (7), 485e494.
Laudner, K.G., Williams, J.G., 2013. The relationship between la-
tissimus dorsi stiffness and altered scapular kinematics among
asymptomatic collegiate swimmers. Phys. Ther. Sport 14 (1),
50e53.
Lawrence, R.L., Braman, J.P., Laprade, R.F., Ludewig, P.M., 2014.
Comparison of 3-dimensional shoulder complex kinematics in
individuals with and without shoulder pain, part 1: sternocla-
vicular, acromioclavicular, and scapulothoracic joints. J.
Orthop. Sports Phys. Ther. 44 (9). 636-A638.
Lewis, J.S., Wright, C., Green, A., 2005. Subacromial impingement
syndrome: the effect of changing posture on shoulder range of
movement. J. Orthop. Sports Phys. Ther. 35 (2), 72e87.
Lin, J.-J., Wu, Y.-T., Wang, S.-F., Chen, S.-Y., 2005. Trapezius
muscle imbalance in individuals suffering from frozen shoulder
syndrome. Clin. Rheumatol. 24 (6), 569e575.
Lopes, A.D., Timmons, M.K., Grover, M., Ciconelli, R.M.,
Michener, L.A., 2015. Visual scapular dyskinesis: kinematics and
muscle activity alterations in patients with subacromial
impingement syndrome. Archives Phys. Med. Rehabil. 96 (2),
298e306.
Lucas, K.R., Rich, P.A., Polus, B.I., 2010. Muscle activation patterns
in the scapular positioning muscles during loaded scapular plane
elevation: the effects of latent myofascial trigger points. Clin.
Biomech. 25 (8), 765e770.
Ludewig, P.M., Braman, J.P., 2011. Shoulder impingement:
biomechanical considerations in rehabilitation. Man. Ther. 16
(1), 33e39.
Ludewig, P.M., Cook, T.M., 2000. Alterations in shoulder kinematics
and associated muscle activity in people with symptoms of
shoulder impingement. Phys. Ther. 80 (3), 276e291.
Ludewig, P.M., Reynolds, J.F., 2009. The association of scapular
kinematics and glenohumeral joint pathologies. J. Orthop.
Sports Phys. Ther. 39 (2), 90e104.
Lukasiewicz, A.C., McClure, P., Michener, L., Pratt, N.,
Sennett, B., 1999. Comparison of 3-dimensional scapular po-
sition and orientation between subjects with and without
shoulder impingement. J. Orthop. Sports Phys. Ther. 29 (10),
574e586.
Matias, R., Pascoal, A.G., 2006. The unstable shoulder in arm
elevation: a three-dimensional and electromyographic study in
subjects with glenohumeral instability. Clin. Biomech. 21,
S52eS58.
McClure, P.W., Bialker, J., Neff, N., Williams, G., Karduna, A.,
2004. Shoulder function and 3-dimensional kinematics in people
399
with shoulder impingement syndrome before and after a 6-week
exercise program. Phys. Ther. 84 (9), 832e848.
McClure, P.W., Michener, L.A., Karduna, A.R., 2006. Shoulder
function and 3-dimensional scapular kinematics in people with
and without shoulder impingement syndrome. Phys. Ther. 86
(8), 1075e1090.
McFarland, E.G., Maffulli, N., Del Buono, A., Murrell, G.A., Garzon-
Muvdi, J., Petersen, S.A., 2013. Impingement is not impinge-
ment: the case for calling it Rotator Cuff Disease. Muscles
Ligaments Tendons J. 3 (3), 196.
Mell, A., Hughes, R., Carpenter, J., 2005a. Effect of rotator cuff
tear size on shoulder kinematics. In: Paper Presented at the
Transactions of the 51st Annual Meeting of the Orthopaedic
Research Society.
Mell, A.G., LaScalza, S., Guffey, P., Ray, J., Maciejewski, M.,
Carpenter, J.E., Hughes, R.E., 2005b. Effect of rotator cuff
pathology on shoulder rhythm. J. Shoulder Elb. Surg. 14 (1),
S58eS64.
Miachiro, N.Y., Camarini, P.M., Tucci, H.T., McQuade, K.J.,
Oliveira, A.S., 2014. Can clinical observation differentiate in-
dividuals with and without scapular dyskinesis? Braz. J. Phys.
Ther. 18 (3), 282e289.
Muth, S., Barbe, M.F., Lauer, R., McClure, P., 2012. The effects of
thoracic spine manipulation in subjects with signs of rotator
cuff tendinopathy. J. Orthop. Sports Phys. Ther. 42 (12),
1005e1016.
Nagai, K., Tateuchi, H., Takashima, S., Miyasaka, J., Hasegawa, S.,
Arai, R., Ichihashi, N., 2013. Effects of trunk rotation on scap-
ular kinematics and muscle activity during humeral elevation. J.
Electromyogr. Kinesiol. 23 (3), 679e687.
Ogston, J.B., Ludewig, P.M., 2007. Differences in 3-dimensional
shoulder kinematics between persons with multidirectional
instability and asymptomatic controls. Am. J. Sports Med. 35
(8), 1361e1370.
de Oliveira Sousa, C., Camargo, P.R., Ribeiro, I.L., de Menezes
Reiff, R.B., Michener, L.A., Salvini, T.F., 2014. Motion of the
shoulder complex in individuals with isolated acromioclavicular
osteoarthritis and associated with rotator cuff dysfunction: part
1ethree-dimensional shoulder kinematics. J. Electromyogr.
Kinesiol. 24 (4), 520e530.
Ozaki, J., 1989. Glenohumeral movements of the involuntary
inferior and multidirectional instability. Clin. Orthop. Relat.
Res. 238, 107e111.
Paletta, G.A., Warner, J.J., Warren, R.F., Deutsch, A.,
Altchek, D.W., 1997. Shoulder kinematics with two-plane x-ray
evaluation in patients with anterior instability or rotator cuff
tearing. J. Shoulder Elb. Surg. 6 (6), 516e527.
Park, M.C., Tibone, J.E., Lee, T.Q., 2012. History, physical exam-
ination, radiographic anatomy, and biomechanics and physio-
logical function of the rotator cuff. Oper. Tech. Sports Med. 20
(3), 201e206.
Phadke, V., Ludewig, P.M., 2013. Study of the scapular muscle la-
tency and deactivation time in people with and without shoul-
der impingement. J. Electromyogr. Kinesiol. 23 (2), 469e475.
Roren, A., Lefevre-Colau, M.-M., Roby-Brami, A., Revel, M.,
Fermanian, J., Gautheron, V., Fayad, F., 2012. Modified 3D
scapular kinematic patterns for activities of daily living in
painful shoulders with restricted mobility: a comparison with
contralateral unaffected shoulders. J. Biomech. 45 (7),
1305e1311.
Roy, J.-S., Moffet, H., McFadyen, B.J., 2010. The effects of unsu-
pervised movement training with visual feedback on upper limb
kinematic in persons with shoulder impingement syndrome. J.
Electromyogr. Kinesiol. 20 (5), 939e946.
Roy, J.-S., Moffet, H., Hebert, L.J., St-Vincent, G., McFadyen, B.J.,
2007. The reliability of three-dimensional scapular attitudes in
healthy people and people with shoulder impingement syn-
drome. BMC Musculoskelet. Disord. 8 (1), 49.
400
Rundquist, P.J., Anderson, D.D., Guanche, C.A., Ludewig, P.M.,
2003. Shoulder kinematics in subjects with frozen shoulder.
Archives Phys. Med. Rehabil. 84 (10), 1473e1479.
Rundquist, P.J., Ludewig, P.M., 2005. Correlation of 3-dimensional
shoulder kinematics to function in subjects with idiopathic loss
of shoulder range of motion. Phys. Ther. 85 (7), 636e647.
Scibek, J.S., Mell, A.G., Downie, B.K., Carpenter, J.E.,
Hughes, R.E., 2008. Shoulder kinematics in patients with full-
thickness rotator cuff tears after a subacromial injection. J.
Shoulder Elb. Surg. 17 (1), 172e181.
Seitz, A.L., McClure, P.W., Finucane, S., Ketchum, J.M.,
Walsworth, M.K., Boardman, N.D., Michener, L.A., 2012. The
scapular assistance test results in changes in scapular position
and subacromial space but not rotator cuff strength in sub-
acromial impingement. J. Orthop. Sports Phys. Ther. 42 (5),
400e412.
Shah, K.M., Clark, B.R., McGill, J.B., Lang, C.E., Mueller, M.J.,
2015. Shoulder limited joint mobility in people with diabetes
mellitus. Clin. Biomech. 30 (3), 308e313.
Singh, J., 2013. Critical appraisal skills programme. J. Pharmacol.
Pharmacother. 4 (1), 76.
Struyf, F., Nijs, J., Baeyens, J.P., Mottram, S., Meeusen, R., 2011.
Scapular positioning and movement in unimpaired shoulders,
shoulder impingement syndrome, and glenohumeral instability.
Scand. J. Med. Sci. Sports 21 (3), 352e358.
Su, K., Johnson, M.P., Gracely, E.J., Karduna, A.R., 2004. Scapular
rotation in swimmers with and without impingement syndrome:
practice effects. Med. Sci. Sports Exerc. 36 (7), 1117e1123.
Thomas, S.J., Swanik, C.B., Swanik, K., Kelly, J.D., 2013. Change in
glenohumeral rotation and scapular position after a Division I
collegiate baseball season. J. Sport Rehabil. 22 (2), 115e121.
Timmons, M.K., Thigpen, C.A., Seitz, A.L., Karduna, A.R.,
Arnold, B.L., Michener, L.A., 2012. Scapular kinematics and
subacromial-impingement syndrome: a meta-analysis. J. Sport
Rehabil. 21 (4), 354.
Vermeulen, H., Stokdijk, M., Eilers, P., Meskers, C., Rozing, P.,
Vlieland, T.V., 2002. Measurement of three dimensional shoul-
der movement patterns with an electromagnetic tracking de-
vice in patients with a frozen shoulder. Ann. Rheum. Dis. 61 (2),
115e120.
Voight, M.L., Thomson, B.C., 2000. The role of the scapula in the
rehabilitation of shoulder injuries. J. Athl. Train. 35 (3), 364.
von Eisenhart-Rothe, R., Matsen III, F., Eckstein, F., Vogl, T.,
Graichen, H., 2005. Pathomechanics in atraumatic shoulder
instability: scapular positioning correlates with humeral head
centering. Clin. Orthop. Relat. Res. 433, 82e89.
von Eisenhart-Rothe, R.M., Jager, A., Englmeier, K.-H., Vogl, T.J.,
Graichen, H., 2002. Relevance of arm position and muscle ac-
tivity on three-dimensional glenohumeral translation in patients
R. Keshavarz et al.
with traumatic and atraumatic shoulder instability. Am. J.
Sports Med. 30 (4), 514e522.
Von Elm, E., Altman, D.G., Egger, M., Pocock, S.J., Gtzsche, P.C.,
Vandenbroucke, J.P., Initiative, S., 2007. The Strengthening the
Reporting of Observational Studies in Epidemiology (STROBE)
statement: guidelines for reporting observational studies. Prev.
Med. 45 (4), 247e251.
Wang, C.-H., McClure, P., Pratt, N.E., Nobilini, R., 1999. Stretching
and strengthening exercises: their effect on three-dimensional
scapular kinematics. Arch. Phys. Med. Rehabil. 80 (8), 923e929.
Warner, J.J., Micheli, L.J., Arslanian, L.E., Kennedy, J.,
Kennedy, R., 1992. Scapulothoracic motion in normal shoulders
and shoulders with glenohumeral instability and impingement
syndrome a study using Moire topographic analysis. Clin.
Orthop. Relat. Res. 285, 191e199.
Wassinger, C.A., Sole, G., Osborne, H., 2013. Clinical measurement
of scapular upward rotation in response to acute subacromial
pain. J. Orthop. Sports Phys. Ther. 43 (4), 199e203.
Williams, J.G., Laudner, K.G., McLoda, T., 2013. The acute effects
of two passive stretch maneuvers on pectoralis minor length
and scapular kinematics among collegiate swimmers. Int. J.
Sports Phys. Ther. 8 (1), 25.
Wilson, K.J., Giphart, J.E., Kagnes, K., Millett, P.J., 2013. Alter-
ations in glenohumeral kinematics in patients with rotator cuff
tears using biplane fluoroscopy. Arthrosc. J. Arthrosc. Relat.
Surg. 10 (29), e124ee125.
Worsley, P., Warner, M., Mottram, S., Gadola, S., Veeger, H.,
Hermens, H., Carr, A., 2013. Motor control retraining exercises
for shoulder impingement: effects on function, muscle activa-
tion, and biomechanics in young adults. J. Shoulder Elb. Surg.
22 (4), e11ee19.
Wu, G., Van der Helm, F.C., Veeger, H.D., Makhsous, M., Van
Roy, P., Anglin, C., Wang, X., 2005. ISB recommendation on
definitions of joint coordinate systems of various joints for the
reporting of human joint motiondPart II: shoulder, elbow, wrist
and hand. J. Biomech. 38 (5), 981e992.
Yamamoto, A., Takagishi, K., Osawa, T., Yanagawa, T.,
Nakajima, D., Shitara, H., Kobayashi, T., 2010. Prevalence and
risk factors of a rotator cuff tear in the general population. J.
Shoulder Elb. Surg. 19 (1), 116e120.
Yang, J.-l., Chang, C.-W., Chen, S.-y., Lin, J.-j., 2008. Shoulder
kinematic features using arm elevation and rotation tests for
classifying patients with frozen shoulder syndrome who respond
to physical therapy. Man. Ther. 13 (6), 544e551.
Yoshizaki, K., Hamada, J., Tamai, K., Sahara, R., Fujiwara, T.,
Fujimoto, T., 2009. Analysis of the scapulohumeral rhythm and
electromyography of the shoulder muscles during elevation and
lowering: comparison of dominant and nondominant shoulders.
J. Shoulder Elb. Surg. 18 (5), 756e763.