䢇

Research Report

Alterations in Shoulder Kinematics and

Associated Muscle Activity in People With
Symptoms of Shoulder Impingement

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Background and Purpose. Treatment of patients with impingement
ўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўў

symptoms commonly includes exercises intended to restore “normal”

movement patterns. Evidence that indicates the existence of abnormal
patterns in people with shoulder pain is limited. The purpose of this
investigation was to analyze glenohumeral and scapulothoracic kine-
matics and associated scapulothoracic muscle activity in a group of
subjects with symptoms of shoulder impingement relative to a group of
subjects without symptoms of shoulder impingement matched for
occupational exposure to overhead work. Subjects. Fifty-two subjects
were recruited from a population of construction workers with routine
exposure to overhead work. Methods. Surface electromyographic data
were collected from the upper and lower parts of the trapezius muscle
and from the serratus anterior muscle. Electromagnetic sensors simul-
taneously tracked 3-dimensional motion of the trunk, scapula, and
humerus during humeral elevation in the scapular plane in 3 hand-
held load conditions: (1) no load, (2) 2.3-kg load, and (3) 4.6-kg load.
An analysis of variance model was used to test for group and load
effects for 3 phases of motion (31°– 60°, 61°–90°, and 91°–120°).
Results. Relative to the group without impingement, the group with
impingement showed decreased scapular upward rotation at the end
of the first of the 3 phases of interest, increased anterior tipping at the
end of the third phase of interest, and increased scapular medial rotation
under the load conditions. At the same time, upper and lower trapezius
muscle electromyographic activity increased in the group with impinge-
ment as compared with the group without impingement in the final 2
phases, although the upper trapezius muscle changes were apparent only
during the 4.6-kg load condition. The serratus anterior muscle demon-
strated decreased activity in the group with impingement across all loads
and phases. Conclusion and Discussion. Scapular tipping (rotation about
a medial to lateral axis) and serratus anterior muscle function are
important to consider in the rehabilitation of patients with symptoms of
shoulder impingement related to occupational exposure to overhead
work. [Ludewig PM, Cook TM. Alterations in shoulder kinematics and
associated muscle activity in people with symptoms of shoulder impinge-
ment. Phys Ther. 2000;80:276 –291.]

Key Words: Biomechanics, Electromyography, Shoulder impingement, Shoulder kinematics.

Paula M Ludewig
ўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўў

Thomas M Cook

276 Physical Therapy . Volume 80 . Number 3 . March 2000

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S
houlder impingement has been defined as com- multiple physical factors, such as holding a tool while
pression and mechanical abrasion of the rotator working overhead.9
cuff structures as they pass beneath the cora-
coacromial arch during elevation of the arm.1,2 Multiple theories exist as to the primary etiology of
Rotator cuff problems are thought to account for nearly shoulder impingement, including anatomic abnormali-
one third of physician visits for shoulder pain com- ties of the coracoacromial arch or humeral head10,11;
plaints.1 The vast majority of people with impingement “tension overload,” ischemia, or degeneration of the
syndrome who are younger than 60 years of age relate rotator cuff tendons12–14; and shoulder kinematic abnor-
their symptoms to occupational or athletic activities that malities.15,16 Regardless of the initial etiology, inflamma-
involve frequent overhead use of the arm.1 Epidemio- tion in the suprahumeral space, inhibition of the rotator
logic investigations3–7 have revealed a high prevalence cuff muscles, damage to the rotator cuff tendons, and
(16%– 40%) of shoulder complaints consistent with altered kinematics are believed to exacerbate the condi-
impingement in certain occupations, including assembly- tion.1,17 Impingement is thought to be due to inade-
line workers, welders, steelworkers, and construction quate space for clearance of the rotator cuff tendons as
workers. Frequent or sustained shoulder elevation at or the arm is elevated.1,10,15 Therefore, factors that further
above 60 degrees in any plane during occupational tasks minimize this space are believed to be detrimental to the
has been identified as a risk factor for the development condition.
of shoulder tendinitis or nonspecific shoulder pain.3,8,9
Evidence relating occupational exposure of frequent or Kinematic changes have been thought to be present in
sustained shoulder elevation to shoulder musculoskele- people with symptoms of impingement and to result in
tal symptoms is strongest for combined exposure to further decreases in the available supraspinatus muscle

PM Ludewig, PT, PhD, is Assistant Professor, Program in Physical Therapy, Department of Physical Medicine and Rehabilitation, Box 388 Mayo,
420 Delaware St, University of Minnesota, Minneapolis, MN 55455 (USA) ([email protected]). Address all correspondence to Dr Ludewig.

TM Cook, PT, PhD, is Professor, Department of Occupational and Environmental Health and Physical Therapy Graduate Program, The University
of Iowa, Iowa City, Iowa.

Dr Ludewig and Dr Cook provided concept and research design, writing, data analysis, project management, and fund procurement. Dr Ludewig
provided data collection, and Dr Cook provided facilities and equipment. Professor James G Andrews, Trudy L Burns, PhD, Warren G Darling,
PhD, Heather D Hartsell, PT, PhD, and H John Yack, PT, PhD, provided assistance with portions of this project. Dr Burns also assisted with data
analysis.

This study was approved by The University of Iowa Human Subjects Institutional Review Board.

This research was presented, in part, at the Combined Sections Meetings of the American Physical Therapy Association; February 12–15, 1998;
Boston, Mass; and February 4 –7, 1999; Seattle, Wash.

This study was supported, in part, by a Doctoral Research Award from the Foundation for Physical Therapy and a
grant from the Centers for Disease Control and Prevention (CDC R49/CCR 703640-05).

This article was submitted February 12, 1999, and was accepted November 23, 1999.

Physical Therapy . Volume 80 . Number 3 . March 2000 Ludewig and Cook . 277
outlet or suprahumeral space.15,17–19 Motions that bring The purpose of our study was to provide a 3-D analysis of
the greater tuberosity in closer contact with the cora- both glenohumeral and scapulothoracic kinematics and
coacromial arch20 are particularly problematic. These associated scapulothoracic muscle activity in subjects
motions include excessive superior or anterior transla- with symptoms of shoulder impingement relative to
tions of the humeral head on the glenoid fossa, inade- subjects without shoulder impairment who were
quate lateral (external) rotation of the humerus, and matched for occupational exposure to overhead work.
decreases in the normal scapular upward rotation and In our study, we assessed both kinematic and EMG
posterior tipping on the thorax, all occurring during factors believed to be related to impingement. Our first
humeral elevation. These kinematic changes have all hypothesis was that subjects with symptoms of shoulder
been purported to occur in patients with symptoms of impingement would have decreased scapular upward
impingement.15,17–20 Additionally, the hypothesized rotation, scapular posterior tipping, and humeral lateral
kinematic alterations in scapular motion have been rotation, as well as increased scapular medial (internal)
linked to decreases in serratus anterior muscle activity, rotation during humeral elevation. Our second hypoth-
increases in upper trapezius muscle activity, or an imbal- esis was that subjects with symptoms of shoulder

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ance of forces between the upper and lower parts of the impingement would have increased upper trapezius
trapezius muscle.17,19,21 muscle EMG activity and decreased lower trapezius and
serratus anterior muscle EMG activity during humeral
Evidence to support the existence of abnormal electro- elevation. Our third hypothesis was these differences
myographic (EMG) or kinematic patterns in people with would be consistent across all phases of the painful arc of
shoulder pain is limited. Investigations of altered scapu- humeral elevation in the scapular plane (60°–120°)
lothoracic EMG patterns in patient populations have (there would be no interaction of group and phase
been nonspecific regarding subject diagnoses or effects). In addition, occupational exposure to holding a
restricted to testing of athletic activities.22–24 Use of tool while working overhead has been more strongly
2-dimensional (2-D) radiographic and fluoroscopic tech- related to shoulder musculoskeletal symptoms than
niques has shown abnormal shoulder kinematics in exposure to overhead work alone.9 The effects of hand-
some subjects with impingement during humeral eleva- held loads (additional weight held in the hand while
tion.25,26 The results of these analyses are difficult to elevating the arm) were also examined. Our fourth
interpret, however, because a variety of diagnoses exist hypothesis was that kinematic differences among sub-
in these patients. More recently, Lukasiewicz et al27 jects would be greater under higher load conditions
quantified 3-dimensional (3-D) scapular orientation at (there would be an interaction of group and load
static positions of arm elevation in the scapular plane by conditions).
comparing subjects with and without impingement syn-
drome. Subjects with impingement syndrome demon- Method
strated less (approximately 8°–9°) posterior (backward)
tipping of the scapula at 90 degrees and at maximal Subjects
elevation as compared with subjects without impinge- The population of interest in this study was people
ment. Additionally, scapulothoracic asymmetry or “abnor- whose occupation involved routine exposure to work
mal moiré patterns” during eccentric shoulder flexion with tasks requiring their upper arms to be at or above
a 4.5-kg load in each hand were reported in a small sample shoulder level. Volunteers were recruited through mail-
of subjects with impingement syndrome.28 ings to workers and announcements at union meetings
from a population of construction workers in the sheet
Conservative treatment of patients with impingement metal and carpentry trades. This population was of
symptoms commonly includes exercise programs particular interest because of their increased risk for
intended to restore “normal” kinematics or muscle activ- developing shoulder problems.3,8,9 In addition, we
ity patterns.16,17,19,29 –31 In particular, the muscular con- believe that people who do not engage in overhead
trol of the scapula has become a recent focus of thera- activities, even though they might not have symptoms of
peutic intervention.17,19 Due to limited scientific data shoulder impingement, may demonstrate abnormal
from which to design exercise programs, these programs kinematic patterns that could contribute to the develop-
often vary widely.16,17,19,30,31 Although previous investi- ment of shoulder impingement if they routinely used
gations have provided important contributions, they are their arms in elevated positions. We believed that equal
often constrained by static analysis,25,27 2-D analysis,25,26 occupational exposure between the 2 groups would
varied patient diagnoses,24,25 a lack of control for expo- improve the potential to detect kinematic or muscle
sure to overhead activity between subjects with and activity differences.
without symptoms of impingement,24 –28 small sample
sizes,22,25,26,28 or other methodologic limitations.22–24,28 The experimental group was limited to people who had
(1) a history of shoulder pain of greater than 1 week in

278 . Ludewig and Cook Physical Therapy . Volume 80 . Number 3 . March 2000
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Table 1.
Subject Demographics

Subjects Without Subjects With

Shoulder Impairment Shoulder Impingement
(nⴝ26) (nⴝ26)
Variable X SD Range X SD Range

Age (y) 39.9 13.3 20 –71 39.7 12.0 25– 68

Height (m) 1.80 0.08 1.67–1.96 1.81 0.06 1.67–1.93
Weight (kg) 85.7 12.7 63.6 –122.7 90.9 14.0 61.4 –120.5
Exposure (y)a 18.1 13.5 2.0 – 43.5 16.7 12.5 3– 42
Average weeks worked per yeara 48.0 6.5 26 –52 47.0 7.6 20 –52
Average hours worked per weeka 42.2 6.6 35– 65 41.9 4.7 40 – 60
Time working overhead (%)a 37.2 20.6 7.5– 80 37.8 20.4 5–75
SPADIb pain scores 27.8 16.2 3.2– 68.8

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SPADI disability scores 19.5 16.8 0.9 – 65.1
SPADI total scores 23.6 15.4 6.3– 67
a
Subject self-reports.
b
Shoulder Pain and Disability Index.

duration, localized to the proximal anterolateral shoul- subjects per group)—met the inclusion and exclusion
der region, (2) a positive impingement sign,2,32 a painful criteria of the investigation. Subjects with symptoms of
arc of movement (60°–120°),33 or tenderness to palpa- shoulder impingement completed the Shoulder Pain
tion in the region of the greater tuberosity, acromion, or and Disability Index (SPADI).39 This shoulder question-
rotator cuff tendons, and (3) shoulder coronal-plane naire consists of 2 subscales: a pain subscale and a
abduction of at least 130 degrees relative to the trunk. disability subscale. Scores on the SPADI can range from
Subjects were excluded from the experimental group if 0 to 100, with higher scores indicating worse function.
any of the following were found during an examination: The SPADI scores and demographic characteristics of
(1) reproduction of symptoms during a cervical screen- the subjects are presented in Table 1. There were no
ing examination (active and resisted range of motion differences between the groups for any of the demo-
[ROM], overpressure, quadrant test),34 (2) abnormal graphic or work exposure variables (2-sample t tests). All
results on thoracic outlet tests (Allen, Adson, Hal- subjects were male. The subjects with shoulder impinge-
stead),35 (3) numbness or tingling in the upper extrem- ment reported the initial onset of symptoms as having
ity, or (4) a history of onset of symptoms due to been an average of 5.5 years (SD⫽3.2, range⫽0.6 –10)
traumatic injury, glenohumeral or acromioclavicular previous to this investigation. Three of the subjects
(AC) joint dislocation, or surgery on the shoulder. reported continual symptoms since onset, with the
There is a lack of reliability data regarding cervical and remainder reporting symptoms to be episodic. All sub-
thoracic outlet tests. Exclusion criteria for the compari- jects continued to work with pain. All subjects read and
son group included: (1) employment in an occupation signed university-approved informed consent docu-
involving overhead work for less than 1 year (possible ments for human subjects prior to participation.
inadequate exposure), (2) less than 150 degrees of
glenohumeral flexion or abduction ROM at the shoul- Instrumentation
der, or visual observation of medial/lateral rotation Electromyographic data were collected with differential
ROM of less than normal limits, or (3) a history of pain, preamplified silver-silver chloride surface electrode
trauma, or dislocation of the glenohumeral or AC joints. assemblies.* These assemblies provide an interelectrode
The first author (PML) performed all assessments for distance of 20 mm with 8-mm-diameter active electrodes
inclusion and exclusion criteria. and an on-site gain of 35. Signals were further amplified
with GCS 67 amplifier* with a high input impedance
Prior to initiating the study, a sample size of 25 subjects (greater than 15 ⍀ at 100 Hz), a common mode rejec-
per group was calculated to provide 80% power to detect tion ratio of 87 dB at 60 Hz, and a bandwidth (⫺3 dB)
differences of 5 degrees or 10% of maximal voluntary of 40 to 4,000 Hz. Root mean square (RMS)-processed
contraction (MVC) between the 2 groups of interest.36 (25-millisecond time constant) signals were collected
Calculations were based on our judgment of what are online with a microcomputer at a sampling rate of 300
clinically meaningful differences and variability esti-
mates from previous studies on subjects without shoul-
der impairment.25,37,38 Fifty-two construction worker vol-
unteers—31 sheet metal workers and 21 carpenters (26 * Therapeutics Unlimited, 2835 Friendship St, Iowa City, IA 52245.

Physical Therapy . Volume 80 . Number 3 . March 2000 Ludewig and Cook . 279
Hz using a 12-bit A/D board (Dash 16F†). Raw signals
were also monitored on an oscilloscope (Hitachi
V-1100A‡) throughout data collection in order to verify
signal quality.

The 3-D position and orientation of each subject’s

thorax, scapula, and humerus were tracked (40-Hz sam-
pling rate) using the Polhemus FASTRAK electromag-
netic motion capture system.§40,41 The sensors were small
and lightweight (2.3 ⫻ 2.8 ⫻ 1.5 cm, 17-g mass), and an
additional sensor attached to a stylus was used to manu-
ally digitize palpated anatomical coordinates. Within a
76-cm source-to-sensor separation, the RMS system accu-
racy is 0.15 degree for orientation and 0.3 to 0.8 mm for

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position.41– 44 This system has been used frequently in
shoulder biomechanics research.37,45– 49 Pilot testing
with the FASTRAK system on and off was done with 5
subjects to determine the separation between the
FASTRAK transmitter and EMG surface electrodes nec-
essary to prevent electromagnetic artifact in the EMG
signal. For all subjects, who maintained a 20.3-cm (8-in)
minimum separation during testing, no electromagnetic
artifact was detectable in the RMS magnitude or spectral
analysis of the EMG signals.

Experimental Procedure
Surface electrodes were placed over the upper trapezius
muscle (two thirds of the distance from the spinous
process of the seventh cervical vertebra to the acromial Figure 1.
(A) Surface electromyographic electrode placements, (B) electromag-
process),50 the lower trapezius muscle (one fourth of the
netic sensor placements.
distance from the thoracic spine to the inferior angle of
the scapula when the arm was fully flexed in the sagittal
plane),51 and the lower serratus anterior muscle (over superior to shoulder elevation in activating the upper
the muscle fibers anterior to the latissimus dorsi muscle fibers of the trapezius muscle. Serratus anterior and
when the arm was flexed 90° in the sagittal plane)52 lower trapezius muscle contractions were performed in
(Fig. 1A). A reference electrode was placed on the distal manual muscle test positions as described by Kendall
ulna of the left wrist. and Kendall,53 with the modification of the 75-degree
humeral elevation position noted earlier. For the serra-
Verification of signal quality was completed for each tus anterior muscle, the subject was seated and resistance
muscle by having the subject perform a resisted contrac- was applied to a forward thrust of the arm and protrac-
tion in manual muscle test positions specific to each tion of the scapula.53 For the lower trapezius muscle, the
muscle of interest.53 As a normalization reference, EMG subject was prone and resistance was applied to the
data were collected during MVCs for each of these forearm downward toward the table.53
muscles with the arm in 75 degrees of humeral elevation
relative to the trunk. This humeral position was the The FASTRAK sensors were attached with adhesive tape
midpoint of the ROM analyzed (30°–120°). Data were to the sternum and to the skin overlying the flat superior
sampled for two 3-second trials during manually resisted bony surface of the scapular acromial process. A third
maximal contractions for each muscle. The highest sensor was attached to a thermoplastic cuff secured to
value (averaged over 500 milliseconds) was used as the the distal humerus with Velcro straps㛳 (Fig. 1B). These
normalization reference. For the upper trapezius muscle surface sensor placements have been used previously
contractions, the subject was seated and resistance was and validated for measurement of scapular upward
applied to abduction of the arm in the scapular plane.54 rotation to 2-D radiographic measurement of in vivo
Schuldt and Harms-Ringdahl54 found this position to be glenohumeral elevation (r 2⫽.94).37 Further testing has
compared similar surface sensor measurement of scapu-
†
Keithly MetraByte, 28775 Aurora Rd, Cleveland, OH 44139.
‡
Hitachi Denshi America Ltd, 150 Crossways Park Dr, Woodbury, NY 11797.
§ 㛳
Polhemus Inc, 1 Hercules Dr, PO Box 560, Colchester, VT 05446. Velcro USA Inc, 406 Brown Ave, Manchester, NH 03108.

280 . Ludewig and Cook Physical Therapy . Volume 80 . Number 3 . March 2000
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Figure 2.
(A) Local coordinate systems for the thorax, scapula, and humerus. C7⫽spinous process of the 7th cervical vertebra, T8⫽spinous process of the 8th
thoracic vertebra, XP⫽xiphoid process, SN⫽suprasternal notch, RS⫽root of the spine of the scapula, IA⫽inferior angle of the scapula,
AC⫽acromioclavicular joint, MR/LR⫽medial rotation/lateral rotation, DR/UR⫽downward rotation/upward rotation, PT/AT⫽posterior tipping/
anterior tipping, ME⫽medial epicondyle, LE⫽lateral epicondyle, AD/AB⫽adduction/abduction, Flex/Ext⫽flexion/extension. Trunk axes are
aligned with the cardinal planes. Xt is directed laterally, Yt is directed anteriorly, and Zt is directed superiorly. Xs is directed laterally from RS to AC,
Ys is directed anteriorly perpendicular to the plane of the scapula, Zs is directed superiorly perpendicular to Xs and Ys, Zh is directed superiorly parallel
to the long axis of the humerus, Yh is directed anteriorly perpendicular to the plane formed by Zh and a line from ME to LE, and Xh is directed laterally
perpendicular to Zh and Yh. (B) Scapular motions.

lar motion during arm elevation to sensors fixed to pins coordinate systems (Fig. 2A). Kinematic and EMG data
embedded in the underlying bones (AR Karduna and were then collected for 5 seconds in this resting standing
colleagues, unpublished research, 1999). In a sample of posture. Humeral elevation in the scapular plane was
8 subjects, average surface measurements of posterior matched to a metronome at one complete cycle every 4
tipping (backward rotation about a medial to lateral seconds and guided to remain in this plane by a flat
scapular axis) at 60, 90, and 120 degrees of scapular- surface oriented 40 degrees anterior to the coronal
plane elevation were within 2 degrees of average mea- plane.38,56 Once the subjects were able to control the
surements from bone-fixed sensors. Additionally, track- speed of motion in the appropriate plane, synchronized
ing of humeral movement by the humeral cuff sensor kinematic and EMG data from 5 repetitions of scapular-
was validated on a subject with an external humeral plane humeral elevation were collected under condi-
fixator. The surface-mounted sensor closely represented tions of no external handheld load and with handheld
the underlying angular movements of the bone (3° RMS loads of 2.3 and 4.6 kg (5 and 10 lb). The order of
error).55 loading conditions was randomized between subjects.
These load values were selected to represent a range of
While subjects stood with their arms relaxed at their handheld loads that might reasonably be imposed on a
sides, bony landmarks on the thorax, scapula, and construction worker from power tools or objects to be
humerus were palpated and digitized to allow transfor- lifted overhead. Subjects were given approximately 2 to 3
mation of the sensor data to local anatomically based minutes of rest between practice and test conditions. All

Physical Therapy . Volume 80 . Number 3 . March 2000 Ludewig and Cook . 281
Table 2.
Within-Day Trial-to-Trial Reliability: Intraclass Correlation Coefficients (Type 2,1)61 for Load and Phase Conditions

Load Condition
No Load 2.3 kg 4.6 kg
31°– 60° 61°–90° 91°–120° 31°– 60° 61°–90° 91°–120° 31°– 60° 61°–90° 91°–120°

Scapular upward
rotation .93 .93 .97 .94 .94 .98 .95 .96 .97
Scapular tipping .98 .98 .97 .97 .97 .97 .96 .97 .97
Scapular medial
rotation .96 .97 .98 .97 .96 .98 .96 .97 .98
Humeral lateral
rotation .97 .97 .98 .97 .97 .97 .97 .98 .98
Upper trapezius

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muscle EMGa .81 .85 .85 .78 .79 .81 .88 .84 .78
Lower trapezius
muscle EMG .84 .82 .90 .83 .82 .88 .83 .86 .82
Serratus anterior
muscle EMG .73 .73 .83 .84 .89 .83 .81 .83 .86
a
EMG⫽electromyographic activity.

subjects were queried regarding the need for additional to the scapula was described as rotation about yh (adduc-
rest to prevent fatigue; however, no subjects required tion/abduction), rotation about x⬘h (flexion/extension)
additional time. The dominant shoulder was tested for and rotation about z⬙h (medial/lateral rotation) (y, x⬘, z⬙
all subjects. Sensors were not removed and replaced Cardan angles, Fig. 2).
between trials. Five subjects returned the day after their
initial testing for repeat testing using the same protocol. For EMG data, minimum values (averaged over 500
milliseconds) were determined during the resting stand-
Data Reduction ing posture, and RMS averages were determined for
Raw kinematic data were low-pass filtered (fourth-order each trial and phase of motion. After subtraction of the
zero-phase shift) at a 4.7-Hz cutoff frequency.57 Absolute minimum rest values, average motion values were
sensor orientation data were transformed to describe expressed as a percentage of the MVC value (motion
relative positions of the local coordinate systems for each values are divided by MVC values and multiplied by
segment. These local coordinate systems are defined in 100).60 This process creates a percentage of MVC value
the Appendix and depicted in Figure 2A.58 These coor- for each phase of motion that represents the activity level
dinate systems allowed the sensors to be placed in beyond the resting standing posture. For all kinematic
locations where skin motion artifact was minimized. and EMG variables, data from the middle 3 of the 5
Sensor orientation was then mathematically rotated to collected motion trials were used in subsequent analyses.
be aligned with anatomically based and clinically mean-
ingful axis systems. Generally, 2 of the anatomical land- Data Analysis
marks defined the first anatomical axis, the combined 3 Intraclass correlation coefficients (ICC [2,1])61 were
or 4 points from a segment defined a plane perpendic- used to establish the trial-to-trial reliability of the kine-
ular to which a second axis was aligned, and the third matic and EMG measurements. Between-day repeatabil-
axis was aligned perpendicular to the first 2 axes. A series ity analysis compared subjects’ values for the same phase
of matrix transformations59 produced a set of 4 ⫻ 4 and load condition over the 2 days and determined the
matrices describing the position and orientation of the within-subjects standard error of the mean. The experi-
scapula and humerus. mental study design used a 3-factor analysis of variance
(ANOVA) model with factors of group (subjects with
Scapular orientation relative to the trunk was subse- shoulder impingement or subjects without shoulder
quently described as rotation about Zs (medial/lateral impingement), load (0-, 2.3-, or 4.6-kg handheld load),
rotation), rotation about Y⬘s (downward /upward rota- and phase of movement (31°– 60°, 61°–90°, and 91°–
tion), and rotation about X⬙s (posterior/anterior tip- 120° of humeral elevation in the scapular plane). These
ping) (z, y⬘, x⬙ Cardan angles, Fig. 2). Humeral orienta- phases were of interest as they comprise the arc of
tion relative to the thorax was described as rotation motion where impingement is believed to occur.20 After
about zh (plane of elevation), rotation about y⬘h (eleva- reliability testing, the remaining analyses used the mean
tion angle), and rotation about z⬙h (axial rotation) (z, of the 3 trials for each subject and condition. The
y⬘, z⬙ Euler angles, Fig. 2). Humeral orientation relative dependent variables included all 3 angular variables for

282 . Ludewig and Cook Physical Therapy . Volume 80 . Number 3 . March 2000
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Figure 3.
Scapular position relative to the trunk and humeral position relative to
the scapula (standing ”rest“ position). Positive values indicate medial
rotation, downward rotation, and posterior tipping. Negative values
indicate lateral rotation, upward rotation, and anterior tipping.

scapular orientation, as well as humeral lateral rotation

relative to the scapula assessed as the position (last data
point) at the completion of each phase and average
normalized RMS amplitudes of each of the 3 selected
scapular muscles throughout each phase. Several anthro-
pometric, demographic, and exposure variables were
considered as possible covariates using analysis of covari-
ance, including age, number of years of exposure to the Figure 4.
trade, percentage of time working overhead, and body Data for representative subject without shoulder impairment (one sub-
weight. However, none of these covariates influenced ject). Asterisk (*) indicates peak lateral rotation.
the results of the analysis, and they were not retained in
the final model. A significance level of .05 was used to
test effects on each dependent variable. Tukey follow-up tation angles represent the angles of the scapula relative
analyses were used to adjust for multiple pair-wise com- to the cardinal planes of the trunk. For example, the
parisons where appropriate. Interaction effects were scapular medial rotation angle is the angle of the
tested first to determine any potential influence on scapular plane relative to the coronal or frontal plane.
group effects. For hypotheses 1 and 2, in the presence of
an interaction, group differences were tested at each Representative kinematic data from a subject in the
level of the interacting variable. In the absence of comparison group during unloaded motion are pre-
interactions, main effects of group (collapsed across sented in Figure 4. Although there was substantial vari-
load and phase) were of interest. For hypotheses 3 and 4, ability among subjects, the general pattern in this group
interaction effects of group and phase and of group and was for the scapula to upwardly rotate and move toward
load, respectively, were of interest. a less anteriorly tipped position as the arm was abducted
in the scapular plane. Simultaneously, the humerus was
Results laterally rotating relative to the scapula throughout most
Trial-to-trial ICC values for the dependent variables of the motion, with peak lateral rotation generally
under each test condition are provided in Table 2. For occurring between 90 and 120 degrees of humeral
the subset of 5 subjects, the standard error of the mean elevation. Based on visual inspection of the graphs, the
for between-day comparisons of all angular variables was subjects with symptoms of shoulder impingement also
2.5 degrees or less for 70% of phase and load conditions demonstrated scapular upward rotation throughout
and 3.3 degrees or less for all phase and load conditions. humeral elevation. However, the scapular tipping pat-
Data from the relaxed standing position for average tern in 31% of this group was toward a more anteriorly
scapular position relative to the trunk and the humeral tipped position as the arm was abducted. In the compar-
position relative to the scapula (Fig. 3) did not differ ison group, only 2 subjects (8%) displayed this pattern of
between groups (P⬎.10, 2-sample t test). Scapular orien- increased anterior tipping throughout arm abduction.

Physical Therapy . Volume 80 . Number 3 . March 2000 Ludewig and Cook . 283
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Figure 5.
Summary kinematic group data. (A) Scapular upward rotation (phase ⫻ group interaction). Asterisk (*) indicates groups significantly different at
60-degree humeral position (F statistic; df⫽1,50; P ⬍.025; n⫽52). (B) Scapular tipping (phase ⫻ group interaction). Asterisk (*) indicates groups
significantly different at 120-degree position (F statistic; df⫽1,50; n⫽52). (C) Scapular medial rotation (group ⫻ load interaction) (F statistic;
df⫽1,50; n⫽52). Asterisk (*) indicates groups significantly different for 2.3- and 4.6-kg load conditions. (D) Humeral lateral rotation (group effects).

Results from the analyses of scapular and humeral degree humeral positions, group means were not differ-
rotations are presented in Figure 5. For upward rotation, ent (1.2°, P⬎.50, and 3.3°, P⬎.10, respectively). At the
the groups responded differently across the phases 120-degree humeral position, the scapular position was
(group ⫻ phase interaction effect, P ⬍.005, hypothesis 5.8 degrees more anteriorly tipped, on average, for the
3). Subsequently, the effects of group were investigated subjects with shoulder impingement than for the com-
for each phase (Fig. 5A). Averaged across all load parison subjects (P ⬍.003, hypothesis 1). There was no
conditions, upward rotation was decreased in the sub- group ⫻ load interaction for this analysis (hypothesis 4).
jects with shoulder impingement (4.1°, P ⬍.025) as
compared with the comparison subjects at the 60-degree Group differences for scapular medial rotation did not
humeral position (hypothesis 1). At the 90-degree depend on the phase of motion (no phase ⫻ group
humeral position, the means were not different. At the interaction effect, hypothesis 3), and subsequently
120-degree humeral position, the means were equiva- results were averaged across phases. The groups
lent. There was no group ⫻ load interaction effect responded differently across load conditions for this
(P⬎.50) for upward rotation (hypothesis 4). variable (group ⫻ load interaction effect, P ⬍.05,
hypothesis 4). Group differences, therefore, were
The analysis of scapular tipping also revealed a group ⫻ assessed for each load condition (Fig. 5C). Under the
phase interaction effect (Fig. 5B, P ⬍.002, hypothesis 3), 2.3- and 4.6-kg load conditions, the subjects with shoul-
and group differences were assessed for each phase. der impingement demonstrated greater scapular medial
Averaged across load conditions, at the 60- and 90- rotation than the comparison subjects (5.2° and 4.4°,

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Figure 6.
Summary electromyographic (EMG) group data (expressed as percentage of maximal voluntary contraction [%MVC]). (A) Upper trapezius muscle
(group effects for each load condition). Asterisk (*) indicates groups significantly different for 61- to 90-degree phase and 91- to 120-degree phase
(F statistic; df⫽1,50; n⫽52). (B) Lower trapezius muscle (phase ⫻ group interaction). Asterisk (*) indicates groups significantly different for 61- to
90-degree phase and 91- to 120-degree phase (F statistic; df⫽1,50; n⫽52). (C) Serratus anterior muscle (group effects). Note changes in scale
between graphs.

respectively), whereas group means were not different interaction effect (P ⬍.003, hypothesis 3). When ana-
for the unloaded condition (hypothesis 1). Figure 5D lyzed for each phase, the subjects with shoulder impinge-
presents the results of the analysis for humeral lateral ment showed increased lower trapezius muscle activity
rotation. There were no group main effects (hypothesis for the 61- to 90-degree and 91- to 120-degree phases
1) or interaction effects (hypothesis 3 and 4). (13% and 17%, respectively; Fig. 6B; hypothesis 2). In
the analysis of serratus anterior muscle EMG activity,
Results from the analyses of the EMG variables are data from 2 of the 52 subjects (1 subject in each group)
illustrated in Figure 6. Upper trapezius muscle group were of inadequate quality and were not used in subse-
differences were influenced by both the phase and load quent analysis. For the remaining subjects (n⫽50), there
conditions (3-way phase ⫻ load ⫻ group interaction was a main effect for group (P ⬍.05, hypothesis 2).
effect, P ⬍.015). Subsequently, the effects of group were Averaged across loads and phases, the subjects with
analyzed at each phase and load combination (Fig. 6A). shoulder impingement demonstrated a 9% reduction in
The subjects with shoulder impingement had more serratus anterior muscle activity (Fig. 6C). There was no
upper trapezius muscle activity for all phases and loads group ⫻ phase interaction for the serratus anterior muscle
compared with the comparison subjects. Differences (hypothesis 3). For both the lower trapezius and serratus
between the groups were noted for the 61- to 90-degree anterior muscles, there were no group ⫻ load effects, and
and 91- to 120-degree phases under the 4.6-kg load results were collapsed across loads (hypothesis 4).
condition (11%, P ⬍.05, hypothesis 2). For the lower
trapezius muscle, there was again a group ⫻ phase

Physical Therapy . Volume 80 . Number 3 . March 2000 Ludewig and Cook . 285
Discussion tion of the anterior acromion as compared with the
In this study, we were primarily interested in comparing lateral acromion in contributing to impingement. Acro-
the 2 groups of subjects and determining whether any mioplasty has changed from early procedures involving
group differences were dependent on phase or load. removal of portions of the lateral acromion to present
With regard to scapular motion, inadequate upward techniques involving removal of portions of the anterior
rotation during the “painful arc of motion” is believed to acromion.2,65
be a potential contributor to the development or pro-
gression of impingement symptoms.17,19 In our investi- Shoulder impingement has been attributed to inade-
gation, decreased upward rotation was noted at the quate lateral rotation of the humerus.65,66 Decreased
completion of the first phase of interest (60° of humeral lateral rotation was believed to result in an inability of
elevation) in the subjects with shoulder impingement. the greater tuberosity of the humerus to pass freely
We believe that this less upwardly rotated scapular beneath the acromion during humeral elevation.47,66
position early in the painful ROM may be detrimental Our data did not support the hypothesis that there
and contribute to impingement. On average, however, would be decreased lateral rotation in subjects with

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the subjects with shoulder impingement appeared to be symptoms of shoulder impingement. The means for
able to gradually compensate for this early decrease lateral rotation showed greater variability than any of the
during the remainder of the ROM of interest. other kinematic measures. Despite the lack of group
differences, it is possible that, in a subset of our subjects,
As the predominant rotation of the scapula relative to a lack of lateral rotation was related to their impinge-
the trunk, upward rotation of the scapula has been most ment symptoms. We could find no data in the literature
commonly addressed in clinical treatment approaches describing in vivo humeral medial/lateral rotation
and research studies.17,25,26,62,63 Upward rotation ele- angles relative to the scapula during elevation of the
vates the lateral acromion and is necessary to prevent arm.
impingement under the lateral acromial edge. However,
posterior tipping elevates the anterior acromion, which We believe the clinical importance of the modest angu-
is the predominant site of impingement.2,20 Although lar kinematic differences in the subjects with shoulder
the range of tipping motion that occurs during elevation impingement (4°– 6° of upward rotation scapular tip-
of the arm is substantially less than that of upward ping and medial rotation) should be considered in light
rotation, it may be more critical to obtaining adequate of the small size of the suprahumeral or subacromial
clearance of the rotator cuff tendons. space. Several researchers20,67,68 have quantified the
suprahumeral space using 2-D radiographs. With the
The tipping results for the 2 groups showed different arm adducted at the side, the acromiohumeral interval
patterns across the phases of interest. The subjects has been generally described as approximately 10 mm in
without shoulder impairment, on average, moved subjects without shoulder impairment. The size of this
toward a less anteriorly tipped position as elevation space is believed to be further diminished with elevation
progressed, whereas the mean of the subjects with of the arm.20,69 The acromiohumeral interval was
shoulder impingement moved toward a more anteriorly reported to gradually decrease with simulated active
tipped position. This pattern in the subjects with symp- elevation of the arm using cadaver specimens, until
toms of shoulder impingement would place the anterior reaching approximately 5 mm by 100 to 110 degrees of
acromion in closer proximity to the rotator cuff tendons elevation in the scapular plane.20 Prior to reaching 90
and increase the potential for impingement. These degrees of elevation relative to the scapula, the subacro-
differences in tipping in the subjects with shoulder mial space must accommodate the articular cartilage,
impingement are consistent with the findings of joint capsule and ligaments, rotator cuff tendons, and
Lukasiewicz et al.27 Support for the importance of pos- subacromial bursa. Using stereophotogrammetric 3-D
terior tipping to elevate the anterior acromion during mapping techniques, Flatow et al20 reported the soft
humeral elevation is provided by previous investigations tissues to be in contact with the undersurface of the
of simulated active scapular plane abduction20 as well as acromion during normal elevation of the humerus. We
passive positioning of the humerus relative to the scap- contend that even subtle decreases in the available
ula64 in cadaver specimens. These authors reported the suprahumeral space could contribute to the initiation or
anterior acromion and coracoacromial ligament to be in progression of shoulder impingement symptoms. This
close proximity to the supraspinatus tendon insertion in process could be further advanced by inflammation in
elevated positions. Flatow et al20 stated that acromial the suprahumeral space, fibrosis or thickening of the
contact with underlying soft tissues always remained on tendons or bursa, or anatomic abnormalities. The mag-
the anterior undersurface. The progression of surgical nitude of the angular differences in tipping and upward
techniques for shoulder impingement is also consistent rotation observed in our investigation were equal to or
with the relative importance of a possible lack of eleva- greater than the 3- to 5-degree anatomical changes in

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acromial slope that have previously been associated with ping, but the lower trapezius muscle may be able to
rotator cuff tears and impingement syndrome.10,11 contribute to posterior tipping during portions of the
range of humeral elevation.72 The scapular tipping data
Abnormal scapulohumeral rhythm or decreases in from our investigation suggest the increases in trapezius
upward rotation of the scapula during humeral elevation muscle activation observed in the subjects with shoulder
have been linked to “imbalances” in force production of impingement were not able to adequately compensate
the upper and lower portions of the trapezius muscle for the decreased serratus anterior muscle activity rela-
and the serratus anterior muscle.17,19,21–23 In particular, tive to this kinematic variable, resulting in a lack of
based on clinical observation, we anticipated increased posterior tipping during the ROM of interest. Consider-
activation of the upper trapezius muscle in subjects with ing the hypothesized clinical importance of posterior
symptoms of shoulder impingement. The results of our tipping to elevate the anterior acromion, the decreased
investigation provided some support for this premise. serratus anterior muscle activity in the subjects with
There were increases in activation of the upper trapezius shoulder impingement may be particularly relevant.
muscle in the subjects with shoulder impingement, but

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these increases did not reach statistical significance until The results of our investigation, with regard to both
the final 2 phases of interest for the 4.6-kg load condi- kinematic and muscle activity data, suggest that
tion. We also hypothesized that the lower trapezius increased attention to serratus anterior muscle function
muscle of subjects with symptoms of shoulder impinge- is warranted in rehabilitation programs for shoulder
ment would demonstrate decreased activation. Contrary impingement. The inclusion of the scapulothoracic mus-
to this expectation, the subjects with shoulder impinge- culature in therapeutic exercise programs is a relatively
ment demonstrated increased lower trapezius muscle recent addition.17,19 Exercise programs vary widely, and
activity for the 61- to 90-degree and 91- to 120-degree general strengthening of all the scapulothoracic muscles
phases. Furthermore, this increase, on average, was is often advocated to “stabilize” the scapula. Other
greater than the increase seen in the upper trapezius rehabilitation programs continue to emphasize only the
muscle. rotator cuff musculature.

We found a decrease in activation of the lower serratus Electromyographic data do not provide a direct measure
anterior muscle in the subjects with shoulder impinge- of muscle force production. Muscle length and the type
ment, which averaged 9% across load and phase condi- and speed of contraction affect the EMG force relation-
tions. Decreased activation of this muscle has been ship. The restriction of between-group comparisons to
suggested to potentially result in abnormal scapular specific phases of motion and the control of the speed of
motion and contribute to impingement symptoms.22,23 motion between subjects were used to improve the
During the 31- to 60-degree phase, the decreased serra- interpretability of the EMG data. In addition, use of a
tus anterior muscle activity was consistent with decreased normalization reference contraction is intended to allow
upward rotation in the subjects with shoulder impinge- comparisons across subjects, conditions, and muscles.73
ment. However, after this phase, despite a continued Consideration was given to a variety of reference con-
lower level of activity in the serratus anterior muscle, the tractions prior to choosing to normalize the data to
upward rotation values equalized between the 2 groups. MVCs. As relative contributions of the upper and lower
At the same time, these final 2 phases were those in portions of the trapezius muscle and serratus anterior
which increased activation of the upper and lower muscle to humeral elevation in the scapular plane were
portions of the trapezius muscle became apparent in the of interest, normalization of all muscles to this dynamic
subjects with shoulder impingement. This finding sug- motion was not a viable option. Controlled submaximal
gests to us that these trapezius muscle alterations were force levels are difficult to obtain for the muscles of
used to compensate for the decreased serratus anterior interest (trapezius and serratus anterior). Subsequently,
muscle activity with regard to the production of upward MVCs in the midrange of motion were used as the
rotation of the scapula. reference contraction.

Changes in scapular tipping in the subjects with shoul- The intent with this choice of normalization is to provide
der impingement, however, became greater as humeral a quantification of the EMG signal relative to its maxi-
elevation progressed across the phases of interest. The mum activity. Because pain might interfere with the
serratus anterior muscle is believed to provide the pri- ability to produce an MVC, all subjects were questioned
mary muscular force to produce posterior tipping of the regarding pain and discomfort with the normalization
scapula and stabilize the scapular inferior angle against contractions. Only 5 of the 26 subjects with shoulder
the thorax during humeral elevation.66,70,71 We find it impingement reported pain or discomfort during any of
more difficult to visualize the potential contributions of the MVCs. Therefore, we did not believe that pain was a
the upper and lower trapezius muscle to scapular tip- substantial confounding factor on the EMG results. If

Physical Therapy . Volume 80 . Number 3 . March 2000 Ludewig and Cook . 287
the subjects with shoulder impingement experienced a ment might be expected to show more substantial alter-
systematic inability to maximally activate the muscles of ations in kinematics or muscle activity. The population
interest, the true group differences in activation of the from which our sample was obtained (workers in sheet
upper and lower portions of the trapezius muscle might metal and carpentry trades) is estimated to be 98% to
be less than those reported. However, in such a scenario, 99% male.7 Although there are no data identifying sex
true serratus anterior muscle group differences would be differences for the dependent variables of interest, the
greater than those reported. We are unaware of any generalizability of the study results to women is uncer-
literature supporting a premise of inhibition to maxi- tain. Additionally, mechanisms of shoulder impinge-
mum contraction occurring selectively among specific ment may differ in elderly individuals or people involved
scapulothoracic muscles in response to pain from sub- in athletic activities. Extrapolation of the results of this
acromial impingement. investigation to these populations is not recommended.

Other limitations common to the use of surface elec- In addition to the acromion, several superior cora-
trodes must also be noted. It is assumed that the signal is coacromial arch structures have been implicated as

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representative of the whole muscle or muscle group of potential impingement sites, including the coracoacro-
interest. There are also potential alterations in the signal mial ligament, coracoid process, or undersurface of the
due to muscle movement below the electrode and cross AC joint.2 Furthermore, although the supraspinatus
talk from nearby muscles. The electrode placements tendon insertion into the humerus has been reported to
were chosen to minimize cross talk from muscles such as be the most commonly affected, any or all of the tendons
the rhomboids and latissimus dorsi. Additionally, EMG of the rotator cuff as well as the long head of the biceps
analyses in this investigation were limited to 2 muscles muscle can be involved in impingement syndromes.33
(the serratus anterior muscle and upper and lower No attempt was made in this investigation to classify
portions of the trapezius muscle). Although these mus- subjects as having various categories of impingement.
cle groups are believed to provide the primary muscular Different impingement sites may relate to unique kine-
control of the scapula, no data are available from this matic abnormalities, making it more difficult to ascer-
study on any of the other scapulothoracic or glenohu- tain overall group differences between subjects with
meral muscles that may impart forces to the scapula. shoulder impingement and subjects without shoulder
impairment.
In addition to direct between-group comparisons, the
effects of handheld loads were of interest with regard to Currently, it is unknown whether kinematic and muscle
possible increases in group differences under loaded activity alterations in subjects with symptoms of shoulder
conditions (interactions of group and load). With the impingement are precursors to the development of
exception of the 3-way interaction of group, phase, and impingement or a result of the condition. Longitudinal
load for the upper trapezius muscle and the group ⫻ studies could allow a determination of whether any
load interaction for scapular medial rotation, there were kinematic or muscle activity patterns, combined with
no interactions of group and load for any of the variables exposure to frequent overhead activities, are predictive
analyzed in this study. This finding may reflect the of the development of impingement symptoms. This
occupational exposures to routine lifting of tools and information may eventually assist in the prevention of
construction materials that subjects in both study groups these and other shoulder disorders.
experience on a daily basis. Previous investigations of the
effects of loads on scapular kinematics have produced Clinical studies have begun to address the effectiveness
varying results.37,62,63,74 Comparisons among studies are of physical therapy for symptoms of shoulder impinge-
hampered by different methods of investigation, as well ment.75 As therapeutic exercise programs evolve, com-
as differences in the handheld loads imposed and sub- parative testing of different rehabilitation approaches is
ject populations tested. needed. To improve our understanding of the mecha-
nisms by which shoulder function is enhanced through
In interpreting our results, we believe that several factors rehabilitation, outcome assessments should address
regarding the subject sample should be considered. The kinematic and muscle activity alterations as well as
population of interest was construction workers from symptoms and functional status.
trades with substantial exposure to overhead work. As
these subjects continued to work despite intermittent Summary and Conclusions
periods of pain, they may have developed compensation The first hypothesis was supported by decreased scapular
strategies that may not be apparent in a population of upward rotation in the first of the 3 phases of interest,
subjects with more acute symptoms. Furthermore, increased anterior tipping in the third phase of interest,
SPADI scores for the subjects with shoulder impinge- and increased scapular medial rotation under the load
ment were relatively low. Subjects with greater impair- conditions for the subjects with shoulder impingement.

288 . Ludewig and Cook Physical Therapy . Volume 80 . Number 3 . March 2000
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However, there were no detectable group differences in 7 Cook TM, Rosecrance JC, Zimmermann CL. The University of Iowa
humeral lateral rotation. The second hypothesis was Construction Survey. Washington, DC: Center to Protect Worker’s
Rights; 1996. Publication No. 010-96.
supported by increased upper trapezius muscle EMG
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contrary to the hypothesized result. The third hypothesis Ohio: US Department of Health and Human Services, Public Health
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lateral rotation, and serratus anterior muscle EMG activ- for Occupational Safety and Health; 1997(3):1–72. Publication No.
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were phase dependent. The fourth hypothesis was sup- 10 Zuckerman JD, Kummer FJ, Cuomo F, et al. The influence of

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290 . Ludewig and Cook Physical Therapy . Volume 80 . Number 3 . March 2000
 ўўўўўўўўўўўўўўўўўўўўўўўўўўў
72 van der Helm FC. Analysis of the kinematic and dynamic behavior
Appendix.
of the shoulder mechanism. J Biomech. 1994;27:527–550. Definitions for Local Coordinate Systems (LCS) for Each Segment
73 LeVeau B, Andersson G. Output forms: data analysis and applica-
tions. In: Soderberg GL, ed. Selected Topics in Surface Electromyography for Thorax:
Use in the Occupational Setting: Expert Perspectives. Cincinnati, Ohio: US Z t: The Kt unit vector corresponding to the positive Zt coordinate
Department of Health and Human Services, Public Health Service, direction of the thorax LCS and approximating the longitudinal axis of
Centers for Disease Control and Prevention, National Institute for the thorax, defined by, Kt⫽[(rSN/O⫹rC7/O)/2⫺(rXP/O⫹rT8/O)/2]/
Occupational Safety and Health; 1992:70 –102. Publication No. 91-100. (rSN/O⫹rC7/O)/2⫺(rXP/O⫹rT8/O)/2, where SN and XP are the
74 van der Helm FCT, Pronk GM. Three-dimensional recording and suprasternal notch and the xiphoid process, and rA/O is a vector
description of motions of the shoulder mechanism. J Biomech Eng. locating point A relative to point O. Point O is defined as the origin of
1995;117:27– 40. the sternal sensor.
X t: The It unit vector corresponding to the positive Xt coordinate
75 Ginn KA, Herbert RD, Khouw W, Lee R. A randomized, controlled direction of the thorax LCS and perpendicular to the plane defined by Kt
clinical trial of a treatment for shoulder pain. Phys Ther. and rC7/SN (formed from their cross product), It⫽Kt⫻(rC7/SN/rC7/SN).
1997;77:802– 809. Yt: The Jt unit vector corresponding the positive Yt coordinate direction
and perpendicular to Kt and It, Jt⫽(Kt⫻Iy).

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The origin of the thorax system is the point SNt.

Scapula:
xs: The is unit vector corresponding to the positive xs coordinate
direction defined by is⫽(rAC/O⫺rRS/O)/(rAC/O⫺rRS/O), where AC
and RS are the most dorsal palpable point of the AC joint and the root
of the spine of the scapula, respectively, and point O is the origin of the
scapula sensor.
ys: The js unit vector corresponding to the positive ys coordinate
direction and perpendicular to the scapular plane, defined as js⫽is⫻
[(rIA/O⫺rAC/O)/rIA/O⫺rAC/O], where IA is the inferior angle of the
scapula.
zs: The ks unit vector corresponding to the positive zs coordinate
direction and defined by ks⫽(is⫻js).
The origin of the scapula system is the acromioclavicular joint.

Humerus:
zh: The kh unit vector corresponding to the positive zh coordinate
direction and approximating the longitudinal axis of the humerus is
defined by kh⫽(rscuff/O⫺ricuff/O)/(rscuff/O⫺ricuff/O), where scuff and
icuff are the superior and inferior points on the humeral cuff, and O is the
origin of the humeral sensor.
yh: The jh unit vector corresponding to the positive yh coordinate
direction is defined by jh⫽kh⫻[(rLE/O⫺rME/O)/rLE/O⫺rME/O], where
LE is the lateral epicondyle and ME is the medial epicondyle.
xh: The ih unit vector corresponding to the positive xh coordinate
direction is defined by ih⫽(jh⫻kh).

Physical Therapy . Volume 80 . Number 3 . March 2000 Ludewig and Cook . 291