Escapula - Ingles

Physiotherapy Theory and Practice
An International Journal of Physical Therapy
ISSN: 0959-3985 (Print) 1532-5040 (Online) Journal homepage: https://www.tandfonline.com/loi/iptp20
Clinical assessment methods for scapular

positioning and function. An inter-rater reliability
study
Camilla Marie Larsen, Karen Søgaard, Henrik Eshoj, Kim Ingwersen & Birgit
Juul-Kristensen
To cite this article: Camilla Marie Larsen, Karen Søgaard, Henrik Eshoj, Kim Ingwersen & Birgit
Juul-Kristensen (2019): Clinical assessment methods for scapular positioning and function. An
inter-rater reliability study, Physiotherapy Theory and Practice
To link to this article: https://doi.org/10.1080/09593985.2019.1579284
Published online: 29 Mar 2019.
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PHYSIOTHERAPY THEORY AND PRACTICE
https://doi.org/10.1080/09593985.2019.1579284
Clinical assessment methods for scapular positioning and function. An inter-

rater reliability study
Camilla Marie Larsen, PhD, PT a,b,c, Karen Søgaard, PhDa,d, Henrik Eshoj, PhD, PTe, Kim Ingwersen, PhD, PTf,
and Birgit Juul-Kristensen, PhD, PTa
a
Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark; bHealth Sciences Research
Center, UCL University College, Odense, Denmark; cDepartment of Physiotheraphy, UCL University College, Odense, Denmark; dOccupational
and Environmental Medicine, University Hospital, Odense, Denmark; eQuality of Life Research Center, Department of Haematology, Odense
University Hospital, Odense, Denmark; fDepartment of Rehabilitation, Hospital Lillebaelt – Vejle Hospital, Vejle, Denmark
ABSTRACT ARTICLE HISTORY

Introduction: The aim of this study was to assess the inter-rater reliability of selected static, semi- Received 21 December 2017
dynamic, and dynamic test assessment methods for evaluation of scapular positioning and Revised 27 November 2018
function. Accepted 17 January 2019
Methods: A standardized three-phase (i.e. training, overall agreement, and actual study) protocol KEYWORDS
for reliability studies was applied on 41 overhead sports participants, aged 18–56 (22 with obvious Reliability; scapular
scapular winging, classified as visibility of the medial or inferior angle border of scapula). Ten dyskinesis; scapular position;
scapular test assessment methods (two static, three semi-dynamic, and five dynamic) were scapular function; clinical
evaluated. test assessment method
Results: Bland–Altman plots showed no funnel effects, although systematic bias and significant
differences between raters were present in three of the methods. ICC values ranged from 0.71 to
0.80 for the static test assessment methods and from 0.25–0.92 for the semi-dynamic test
assessment methods. Three of the five dynamic test assessment methods had ICCs of 0.47–0.68.
For the two remaining dynamic test assessment methods, kappa varied between −0.034 and 0.71.
Using PABAK, kappa increased to 0.54–0.86.
Conclusion: Four scapular test assessment methods (Upper horizontal distance, Lower horizontal
distance at max shoulder flexion, Acromial distance, and Winging scapula) showed satisfactory
inter-rater reliability. Simple visual observational methods and quantitative distance measure-
ments have better reliability between clinicians than more complex measurements and may be
better suited for use in clinical practice.
Introduction (Comerford and Mottram, 2001; Kibler and McMullen,

2003; Mottram, 1997). Static evaluations of scapula are
Evaluation of the scapular position and function is
proposed to provide insight into soft tissue adaptations
a fundamental component of the clinical examination
or postural changes, while dynamic evaluation of scapu-
of patients with shoulder pain and disorders. Evidence
lar function offers insight into alterations in scapular
has revealed that some aspects of scapular position and
control and movement. Alterations in static scapular
scapular motor control are altered in patients with
position during rest (arms at side) are suggested to be
shoulder disorders (e.g. rotator cuff-related shoulder
present if at least one of the following conditions exist:
pain/impingement syndrome) (Ludewig and Reynolds,
(1) excessive upward rotation (frontal plane); (2) anterior
2009; Struyf et al., 2011). The muscular system has been
tip/tilt (sagittal plane); and (3) internal rotation/winging
described as a fundamental component of alterations of
(horizontal plane) (Struyf et al., 2009).
both the passive positioning and active functional stabi-
Dyskinesis should not automatically be regarded as
lity of the scapula (Cools et al., 2003; Lopes et al., 2015;
impairment related to shoulder pain or decreased
Nijs, Roussel, Vermeulen, and Souvereyns, 2005).
shoulder function, but may instead be considered part
Scapular dyskinesis is a general term suggested to cover
of a normal variation of scapular position, movement,
reduced control of scapular motion during coupled sca-
or adaption to external requirements as overhead activ-
pulohumeral and scapulothoracic movements
ities (Burn et al., 2016; McQuade, Borstad, and De
CONTACT Camilla Marie Larsen [email protected] Department of Sports Science and Clinical Biomechanics, University of Southern Denmark,
Campusvej 55, Odense 5230, Denmark
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/iptp.
© 2019 Taylor & Francis Group, LLC
2 C.M.LARSEN ET AL.
Oliveira, 2016; Plummer et al., 2017). In overhead ath- Watson, Balster, Finch, and Dalziel, 2005), thereby pro-
letes or throwing athletes scapular dyskinesis has been viding good measures of stability when a measurement is
reported to be more common due to heavy reliance on repeated under identical conditions by the same rater.
unilateral upper extremity function (Burn et al., 2016; However, it is also important to evaluate reliability
Cools, Johansson, Borms, and Maenhout, 2015; Struyf across raters. In this aspect, some of the scapular test
et al., 2012). assessment methods have been assessed for inter-rater
However, even though dyskinesis by itself is not an reliability, and, in general, also show satisfactory reliability
injury or a musculoskeletal diagnosis, it has been pro- (Lange et al., 2016; Struyf et al., 2009). Most often, the
posed as a risk factor for developing shoulder pain studies have not followed recommended standardized
(Clarsen et al., 2014; Hickey et al., 2018). When diagnos- trial designs and provided transparent presentations of
ing shoulder pathology, an integral component of the reliability results, thereby introducing bias that may ham-
clinical examination is to establish the presence or per the external validity. Furthermore, no other studies
absence of scapular dyskinesis, and to evaluate alterations have included participants on the basis of the index con-
of the scapular resting position and related causative dition scapular dyskinesis, which the clinical assessment
factors, such as soft tissue adaptions (Kibler et al., 2013; methods measurements are intended to assess. As
Kibler and Sciascia, 2010; Kibler, Sciascia, and Wilkes, a consequence, there is a need for high-quality studies
2012). Therefore, there is a need for development of investigating intra- and inter-rater reliability of tests used
validated and appropriate static and dynamic assessment for the assessment of scapular position and function
methods to be able to test for any relationship in a clinical (Lange et al., 2016). Additionally, we need to further
setting. Furthermore, evidence-based rehabilitation of develop our knowledge regarding the quantitative assess-
shoulder pain and disorders requires appropriate clinical ments, since criteria for presence/absence of scapular
test assessment methods with the ability to detect changes alterations are lacking (Cools, Johansson, Borms, and
after treatment (De Mey, Danneels, Cagnie, and Cools, Maenhout, 2015; Juul-Kristensen et al., 2011). Therefore,
2012; Ellenbecker and Cools, 2010; Struyf et al., 2013). the overall aim of this study was to assess the inter-rater
Several methods have been developed to objectively assess reliability of selected static, semi-dynamic, and dynamic
the degree of scapular dyskinesis: visual evaluation and test assessment methods in frontal, sagittal, and horizon-
quantitative measurements of static and dynamic scapular tal planes of reference for evaluation of scapular position-
positioning relative to the trunk by electromagnetic ing and function in overhead sports participants
devices (Ludewig and Cook, 2000; Morais and Pascoal, presenting with and without scapular dyskinesis.
2013; Shaheen et al., 2013); either three-dimensional (3D)
or two-dimensional; and more clinically applicable meth-
ods (Johnson, McClure, and Karduna, 2001; Juul- Methods
Kristensen et al., 2011; Tate et al., 2009). Evaluation of
Study design and procedures
scapular dyskinesis in a clinical setting composes
a challenge due to the 3D movements of the scapula, Reporting of the present inter-rater reliability study gener-
and the limited possibility to measure scapular move- ally follows the ‘Guidelines for Reporting Reliability and
ments beneath soft tissue. The clinimetric properties of Agreement Studies’ (GRRAS) (Kottner et al., 2011). To
such clinically practical scapular test assessment methods optimize the design for analyzing reliability of the included
seem to differ and others have not been investigated clinical scapular test assessment methods, a three-phase
(Lange et al., 2016; Struyf et al., 2012). Furthermore, study was performed as described in a standardized proto-
a systematic review concluded that none of the included col for diagnostic procedures in reproducibility and validity
scapular test assessment methods have been examined for studies (Patijn and Remvig, 2007). The clinical test assess-
all three domains: reliability, validity, and responsiveness ment methods (Table 1; Appendices 1 and 2) cover three
(Larsen, Juul-Kristensen, Lund, and Søgaard, 2014). As an categories: (1) Static positioning test assessment methods
initial step, good reliability is a necessary condition for (measurement/observation during static positioning),
a measurement method to be valid and responsive to Lower horizontal distance (cm) (Juul-Kristensen et al.,
change (Mokkink et al., 2010). Previous studies have 2011; Kibler, 1998), and Upper horizontal distance (cm)
shown fair to excellent intra-rater reliability of various as measures of lateral linear scapular placement in relation
static and dynamic test assessment methods for scapular to the spine (Juul-Kristensen et al., 2011); (2) Semi-dynamic
position and function (Johnson, McClure, and Karduna, positioning test assessment methods (static measurement/
2001; Juul-Kristensen et al., 2011; McClure et al., 2009; observation in different joint positions): Acromial distance
Nijs et al., 2007; Nijs, Roussel, Vermeulen, and (Modified Host) (cm) (Struyf et al., 2009), Lower horizontal
Souvereyns, 2005; Struyf et al., 2009; Tate et al., 2009; distance at maximum shoulder flexion (cm) (Juul-
PHYSIOTHERAPY THEORY AND PRACTICE 3
Table 1. Overview and descriptions of the 10 clinical scapular test assessment methods: marked with numbers 1–10: Static
positioning assessment (n = 2); Semi-dynamic positioning assessment (n = 3) and Dynamic functional assessment (n = 5).
Clinical scapular test assessment
methods Description
Static positioning assessment (n = 2);
1) Lower horizontal distance Distance between the inferior angle of the scapula and the corresponding spinous
(cm) t1 process of the thoracic vertebrae, during rest (ad modum Kibler) (Juul-Kristensen
et al., 2011; Kibler, 1998).
2) Upper horizontal distance Distance between the root of the spine of the scapula and the corresponding
(cm) t2 spinous process of the thoracic vertebrae, during rest (Juul-Kristensen et al., 2011).
Semi-dynamic positioning
assessment (n = 3);
3) Lower horizontal distance, Difference between the inferior angle of the scapula and the corresponding
max shoulder flexion (cm) t3 spinous process of the thoracic vertebrae in maximum arm flexion (Juul-Kristensen
et al., 2011).
4) Acromial distance The participants, standing with heels and back against a wall, had their horizontal
(modified Host) t4 distance from the posterior border of the acromion to the wall measured. Two
Horizontal distance from measurements were made: one in relaxed standing position and one with both
acromion to scapulae actively moved toward the wall (Struyf et al., 2009).
wall at rest (cm), and at
scapula retraction (cm)
5) Scapular upward rotation Two plurimeter-V gravity inclinometers were attached: one inclinometer, Velcro
(°) t5 taped to the distal end of the humerus, was used to determine total shoulder
abduction. The other inclinometer was manually positioned along the spine of the
scapula to measure the degree of scapular upward rotation. Five measurements
were made in different arm abduction angles: at rest, 45°, 90°, 135° and at end
range (Watson, Balster, Finch, and Dalziel, 2005).
Dynamic functional
assessment (n = 5);
6) Initial scapular movement The upper arm angle in the sagittal plane was measured with an inclinometer
(°) t6 when initial scapular movement was registered (Juul-Kristensen et al., 2011).
7) Proprioception\reposition Active proprioception/reposition error of the scapula during scapular setting,

error (cm) t7 measured with a laser pointer (Juul-Kristensen et al., 2011; Mottram, 1997)
(Continued )
4 C.M.LARSEN ET AL.
Table 1. (Continued).
Clinical scapular test assessment
methods Description
8) Maximum passive shoulder Internal rotation without scapular fixation, measured with an inclinometer
internal rotation (°) t8 (McClure, Michener, Karduna, and Whitman, 2006).
9) Winging scapula (yes/no) W1: During slow arm extension while holding 1.5 kg in each hand, participants
t9 were observed from the back for scapular winging; pseudo and/or margo medialis
winging (Juul-Kristensen et al., 2011; Mottram, 1997; Schmitt and Snyder-Mackler,
1999).
W2: During rest, participants were observed from the back for scapular winging
(Juul-Kristensen et al., 2011; Mottram, 1997; Schmitt and Snyder-Mackler, 1999).
W3: During slow arm extension without an external load, participants were
observed from the back for scapular winging (Juul-Kristensen et al., 2011; Mottram,
1997; Schmitt and Snyder-Mackler, 1999).
10) Scapular observation (yes/ Participants were asked to perform five shoulder flexions and extensions while
no) t10 holding 1 kg in each hand. They were instructed to maintain a steady pace of five
seconds movement in each direction, estimated by a metronome. Meanwhile,
participants were observed from behind according to the following scapular
conditions; a)Pseudo-winging, b) Margo medialis winging, c) Winging AND pseudo
winging, d) Depressed scapula (clearly depressed)/Elevated scapula (clearly
elevated), e) Protraction – margo medialis visible in a translational movement, f)
Upward rotation – scapular rotation within first 60° of humeral elevation, g)
Rotation – margo medialis not parallel with the vertebral column at rest. Modified
from (Struyf et al., 2009) and (McClure et al., 2009).
Kristensen et al., 2011), and Scapular upward rotation (°) and women, were recruited from Sports Clubs in Denmark,
(Watson, Balster, Finch, and Dalziel, 2005); and (3) with a minimum age of 18 years. No further inclusion or
Dynamic functional test assessment methods (observation exclusion criteria were used. All participants were initially
during dynamic movement/isometric hold): Initial scapular pre-screened at indoor sports facilities or in examination
movement (°) (Juul-Kristensen et al., 2011), Active proprio- rooms at a local department of Physical Therapy. Each
ception/reposition error (cm) (Juul-Kristensen et al., 2011; participant received verbal and written information about
Mottram, 1997), Maximum passive shoulder internal rota- the study and signed a written consent form, which con-
tion (°) (McClure, Michener, Karduna, and Whitman, formed to the Declaration of Helsinki 2008, approved by
2006), Winging scapula (yes/no) (Juul-Kristensen et al., the Regional Committees on Health Research Ethics for
2011; Mottram, 1997; Schmitt and Snyder-Mackler, 1999), Southern Denmark (Project ID S-20090090).
Scapular observation (yes/no) of various scapular condi- Participants were classified into scapular dyskinesis
tions (McClure et al., 2009; Struyf et al., 2009). groups determined by visual inspection of the scapula
The three-phase study consists of: (1) a training phase; as winging (WING) and no-winging (No-WING) dur-
(2) an overall agreement phase (>80% agreement ing a maximum of five slow full shoulder flexion move-
required); and (3) an actual study phase. Based on these ments with the arm externally rotated and thumbs
recommendations, phases 1, 2, and 3 are suggested to pointing at the sealing.
require about 10, 20, and 40 participants, respectively. To be classified into the WING group, at least one of
To describe clinimetric properties, this article uses the the winging conditions had to be present. Scapular
definitions of reliability and measurement error recom- winging (yes/no), was defined as ‘true winging’ (i.e.
mended in the COnsensus-based Standards for the selec- entire medial border of scapula visible) or ‘pseudo
tion of health Measurement INstruments (COSMIN) winging’ (i.e. inferior angle of scapula visible) (Kibler
(Mokkink et al., 2010; Schellingerhout et al., 2011). et al., 2002). In the case of bilateral scapular winging,
the dominant side of the upper extremity was assessed.
If no winging was present, the dominant side of the
Participants and settings
upper extremity was assessed. The classification of par-
A convenience sample of overhead sports participants ticipants was carried out prior to the examination ses-
(water polo/handball/badminton), made up of both men sion and performed by two study coordinators not
involved in the actual examination to avoid bias during proceed to the study phase, an overall rater agreement
testing. Any winging condition needed to be clearly above 80% (in the dichotomized variable dyskinesis/no-
obvious to both coordinators. dyskinesis, called Winging scapula/no-Winging scapula),
The study coordinator completed basic information and a correlation of at least r 0.75 (in the continuous
forms with group classification and personal informa- variable, Lower horizontal distance) were required.
tion about the participants, such as age and gender. Although these requirements were fulfilled, additional
Also, the WING group had to represent approximately refinements were performed for five of 10 test assessment
50% of the included participants in each test phase, as methods (Scapular upward rotation (°), Initial scapular
recommended (Patijn and Remvig, 2007). To minimize movement (°), Proprioception/reposition error (cm),
bias, raters were separated into different rooms and Maximum passive shoulder internal rotation (°), and
mutually blinded to each other’s test results, as well as Scapular observation assessment (yes/no) due to relatively
group classification of the participants. Also, raters low rater agreement and poor correlation estimates.
were only told whether to perform left/right side scap- Furthermore, five more participants were included and
ular test assessments. Finally, the included participants assessed in this phase. Thus, the overall agreement phases
were instructed not to reveal any information about were finally completed with the blinded rater examination
their test results or group classification to the raters. of 25 participants (comprising 14 males, 52% prevalence
Within a week after the group classification, two of scapular winging and mean age of 26.0 ± 4.9 years).
certified physical therapists (Rater A and B), with
a minimum of 6 months’ clinical experience, performed
all the scapular test assessment methods. Rater A tested Study phase (actual reliability study)
half of the participants first, and rater B the other half
In the actual study phase, blinded raters assessed a new
first with nine of the 10 assessment methods being
sample of 41 participants, including 23 males with
evaluated. All nine test assessments were repeated
a prevalence of scapular winging, of 54% and a mean
three times in a predefined order. The tenth and final
age of 25 ± 9.0 years.
test was a fatiguing test and therefore performed and
evaluated only once by both raters, at the same time.
However, mutual blinding of test results was assured. Statistical analysis
Finally, on the day of testing, the participants com-
pleted the Disabilities of the Arm, Shoulder and Hand QQ plots and the Shapiro–Wilk test of continuous variables
(DASH) outcome questionnaire (Hudak et al., 1996; showed data to be normally distributed and therefore t-test
Schønnemann, Larsen, Hansen, and Søballe, 2011). and Chi-square were applied to assess for demographic
group differences. Descriptive statistics were used to
describe demographiccharacteristics, such as age and sex
Training phase in each group (WING/No-WING).
In this phase, a standardized protocol, including pre- For the continuous variables, paired t-test was used to
viously recommended test assessment methods (Larsen, evaluate systematic differences between the two raters. An
Juul-Kristensen, Lund, and Søgaard, 2014), was described Inter-Class-Correlation Coefficient (ICC) between the two
(performance, interpretation), with Raters A & B receiving raters A and B was estimated with the corresponding 95%
a comprehensive training in an open forum format. In confidence interval (CI) using a two-way random model
total, 10 test assessment methods were evaluated (Table 1). 2.1 (Portney and Watkins, 2000). Interpretation of the ICC
All assessment procedures lasted approximately one hour was performed according to the following criteria: poor
per participant. (0.0–0.50), moderate (0.51–0.75), good (0.76–0.90), or
The training phase included 10 participants (with and excellent (0.91–1.00) (Portney and Watkins, 2000).
without a clear winging condition) and any differences Furthermore, Bland-Altman plots (Bland and Altman,
between the two raters’ verbal instructions, measurement 1986) with 95% limits of agreement (LOA) were calculated
procedures and interpretations were identified, with con- to illustrate measurement errors and systematic differences.
sensus ultimately achieved before continuing to the over- The standard error of measurement (SEMconsistency) was
p
all agreement phase. calculated with the formula SEM = SD× 2, where SD is
the standard deviation of the mean rater difference (De
Vet, Terwee, Mokkink, and Knol, 2011). Minimal
Overall agreement phase Detectable Change (MDCindividual) was calculated by multi-
pffiffiffi
In the overall agreement phases data were initially ana- plying SEM by 1.96 × 2, and MDC%, was calculated as its
lyzed after the assessment of 20 participants. In order to percentage over the mean score of each measure. MDC
6 C.M.LARSEN ET AL.
values represent the minimum amount of change beyond by DASH (Table 3). As expected, due to the study
measurement error (De Vet, Terwee, Mokkink, and Knol, design, groups differed on presence of scapular wing-
2011). For the dichotomous variables, McNemar’s test was ing, at either the inferior angle and/or the medial bor-
used to test for significant inter-rater differences (dichot- der of the scapula (22 vs. 0; P < 0.001).
omous variables). Results from the test assessment meth-
ods with dichotomous scores are presented in a 2 × 2
contingency table (Table 2). Observed and expected agree- Inter-rater reliability
ments were calculated along with prevalence and bias
Table 4 presents summary statistics for the scapular test
indices (Sim and Wright, 2005; Patijn and Remvig, 2007)
assessment methods with continuous scores (mean, SD,
and Cohen’s kappa (k) with 95% CI. Kappa was interpreted
range) for both raters. In general, Bland–Altman plots for
as: poor (≤ 0.00), slight (0.01–0.20), fair (0.21–0.40), mod-
continuous scores in static, semi-dynamic and dynamic
erate (0.41–0.60), substantial (0.61–0.80), and almost per- test assessment methods showed no funnel effects
fect (0.81–1.00) (Landis and Koch, 1977). (Figure 1).
All data were collected on paper sheets and data were
entered twice to reduce potential data entry errors. All
statistical tests were two-tailed, level of significance set at
Static test assessment methods (two)
P < 0.05 and data analyses performed by IBM Statistics
SPSS® (v23, IBM Corp, Armonk, NY, USA). For the two test assessment methods (Lower horizontal
distance and Upper horizontal distance), both measured
in cm, ICC ranged from 0.71 to 0.80 (‘moderate’ to ‘excel-
lent’), highest for Upper horizontal distance, and SEM
Results
ranged from 0.67 to 0.76 cm and MDC from 1.84 to
The groups (WING (n = 22) and No-WING (n = 19)) 2.11 cm, corresponding to MDC% from 21.1% to 23.2%
were comparable on demographical variables, as well as (Table 5). Systematic between-rater differences were found
on upper extremity function and symptoms measured in the Lower horizontal distance assessment method.
Table 2. Contingency tables with findings from Rater A and Rater B.
Winging scapula (yes/no)
W1 (ext. with B W2 (rest) B W3 (ext. B

load) without
Yes No Yes No load) Yes No
Yes 17 4 Yes 2 0 Yes 13 3
A A A
No 2 18 No 7 32 No 4 21
Scapular observation (yes/no)
Pseudo- B Winging B Winging & B

winging pseudo-
Yes No Yes No winging Yes No
Yes 7 7 Yes 3 2 Yes 1 2
A
No 2 25 A No 8 28 A No 4 34
Elevated/ B Protracted B Upward B

Depressed rotation
Yes No Yes No Yes No
Yes 0 0 Yes 0 0 Yes 0 0
A
No 2 39 A No 0 41 A No 0 41
Margo B
medialis
rotation Yes No
Yes 0 1
A
No 2 38
Table 3. Study phase. Demographics and self-reported health status for the scapular winging (WING) and No-winging (No-WING)
groups.
WING
Demographic details (n = 22) No-WING (n = 19) P-values
Sex (women/men) (n) 8/14 10/9 0.36
Age (years) mean (SD) 23 (3.6) 28 (11.0) 0.06
Scapular winging of the inferior angle (n, %) 14 (63%) 0 <0.01
Scapular winging of the medial border (n, %) 7 (32%) 0 <0.01
Scapular winging of both the inferior angle and the medial border (n, %) 1 (0.1%) 0 -
Left/right shoulder assessment (n, %) 11 (50%)/11 (50%) 9 (47%)/10 (53%) 1.00
DASH-score (0–100) (SD) 4.8 (6.2)a 4.0 (5.1)d 0.73
DASH-work (0–100) (SD) 2.8 (8.3)b 5.4 (9.9)e 0.58
DASH-sport (0–100) (SD) 10.8 (15.0)c 9.4 (10.7)f 0.81
DASH: Disability of the Arm, Shoulder and Hand Questionnaire; Mean ± SD.
a
n = 14%; bn = 9%; cn = 14%; dn = 10%; en = 7%; fn = 10%.
Table 4. Summary statistics (mean, SD, range) are given for Rater A and Rater B on static (n = 2), semi-dynamic (n = 3), and dynamic
(n = 2) clinical scapular test assessment methods with continuous scores.
Test assessment methods N Mean (SD) Range
Rater A
Static positioning assessment:
Lower horizontal distance (cm) 41 8.69 (1.13) 6.63–11.27
Upper horizontal distance (cm) 41 8.62 (1.24) 4.67–11.50
Semi-dynamic positioning assessment:
Lower horizontal distance, max flexion (cm) 41 19.34 (1.72) 16.70–23.10
Acromial distance (modified Host);
Acromion – wall, rest 41 9.04 (1.7) 5.40–12.57
Acromion – wall, retract. 41 5.87 (1.94) 1.53–9.37
Scapular upward rotation (°)
Scapular position, at rest 41 0.44 (1.68) −4.00–6.00
Scapular position, at 45° 41 8.02 (3.20) 2.00–16.00
Scapular position, maximal shoulder abduction 41 42.39 (6.55) 28.00–58.00
Dynamic functional assessment:
Initial scapular movement (°) 41 66.31 (7.96) 50.67–85.33
Proprioception\reposition error (cm) 41 13.30 (6.33) 2.83–26.43
Maximum passive shoulder internal rotation (°) 41 162.84 (11.84) 136.67–188.00
Rater B
Lower horizontal distance (cm) 41 9.51 (1.15) 7.57–11.73
Upper horizontal distance (cm) 41 8.79 (1.03) 5.67–11.23
Lower horizontal distance, max flexion (cm) 41 19.37 (1.43) 17.07–22.17
Acromion – wall 41 9.00 (1.76) 6.03–13.83
Acromion – wall, retract. 41 5.83 (1.90) 1.47–10.37
Scapular position, at rest 41 1.71 (1.90) −4.00–5.33
Scapular position, maximal shoulder abduction 41 48.42 (4.10) 42.67–58.00
Dynamic functional assessment;
Initial scapular movement (°) 41 67.74 (6.60) 54.00–80.67
Proprioception\reposition error (cm) 41 12.23 (6.82) 3.50–33.00
Maximum passive shoulder internal rotation (°) 41 160.39 (10.69) 132.67–174.67
Semi-dynamic test assessment methods (three) The Scapular upward rotation assessment method is
measured in degrees and with ICC ranging from 0.25 to
For the two test assessment methods measured in cm
0.47 (‘poor’), SEM ranging from 1.66 to 4.98 degrees, and
(Lower horizontal distance at maximun shoulder flexion;
MDC ranging from 4.59 to 13.80 degrees, corresponding to
and Acromial distance, rest/retraction), ICC ranged from
MDC% of 21.1–427.7% (Table 5). Within the Scapular
0.82 to 0.92 (‘excellent’), with SEM ranging from 0.69 to
upward rotation assessment systematic between-rater dif-
1.05 cm, and MDC from 1.92 to 2.90 cm, corresponding
ferences were found for two of the measurements (i.e.
to MDC% from 10.50% to 49.6% (Table 5).
scapular position at rest and maximal shoulder abduction).
8 C.M.LARSEN ET AL.
Static positioning assessment
Semi-dynamic positioning assessment
Dynamic functional assessment
Figure 1. Examples of Bland-Altman plots from the categories of static, semi-dynamic, and dynamic functional assessment with
inter-rater differences (Y-axis) and the mean of raters (X-axis) with 95% limits of agreement for each of the tests. The black line
(y = 0.0) is the perfect mean difference, the green line is the observed mean difference and the red lines are the limits of agreement.
Table 5. Inter-rater reliability of the 10 clinical scapular test assessment methods: distributed into three categories: 1) Static positioning assessment methods (n = 2); 2) Semi-dynamic
positioning assessment methods (n = 3); and 3) Dynamic functional assessment methods (n = 5).
Mean diff ICC 95% limits of
Clinical scapular test assessments methods (SD) P-value (95% CI) agreement SEM MDC (%)
Static positioning assessment (n = 2):
Lower horizontal distance (cm)* −0.81 (1.08) <0.001 0.71 (0.46–0.85) (−2.92–1.31) 0.76 2.11 (23.2)
Upper horizontal distance (cm) −0.17 (0.94) 0.245 0.80 (0.62–0.89) (−2.01–1.67) 0.67 1.84 (21.1)
Semi-dynamic positioning assessment (n = 3):
Lower horizontal distance, max −0.03 (1.00) 0.865 0.89 (0.79–0.94) (−1.99–1.93) 0.71 1.96 (10.1)
shoulder flexion (cm)
Acromial distance (modified Host) Acromion – wall, rest 0.05 (0.98) 0.770 0.92 (0.84–0.95) (−1.87–1.97) 0.69 1.92 (21.3)
Horizontal distance from acromion to Acromion – wall, 0.04 (1.48) 0.870 0.82 (0.68–0.91) (−2.86–2.94) 1.05 2.90 (49.6)
wall (cm) and at scapular retraction scapular retraction
(cm)
Scapular upward rotation (°) Scapular position, at rest* −1.27 (2.34) 0.001 0.25 (−4.00–0.60) (−5.86–3.32) 1.66 4.59 (427.7)
Scapular position, at 45° −0.63 (3.62) 0.269 0.37 (0.18–0.67) (−7.73–6.47) 2.56 7.10 (85.2)
Scapular position, at 90° −0.33 (5.55) 0.709 0.41 (0.11–0.69) (−11.20–10.54) 3.92 10.8 (47.6)
Scapular position, at 135° 0.14 (7.04) 0.901 0.47 (0.01–0.72) (−13.66–13.94) 4.98 13.80 (39.0)
Scapular position, maximal shoulder abduction* −6.03 (6.73) <0.001 0.38 (0.17–0.70) (−19.22–7.16) 4.76 13.19 (29.1)
Dynamic functional assessment (n = 5):
Initial scapular movement (°) −1.43 (8.68) 0.297 0.47 (−0.02–0.71) (−18.44–15.58) 6.14 17.01 (25.4)
Proprioception\reposition error (cm) 1.07 (6.50) 0.297 0.68 (0.39–0.83) (−11.68–13.81) 4.60 12.75 (99.9)
Maximum passive shoulder internal rotation (°) 2.45 (12.80) 0.228 0.53 (0.11–0.75) (−22.64–27.54) 9.05 25.09 (15.5)
Observed Bias Kappa
agreement Expected agreement Prevalence index index (95% CI) PABAK
Winging scapula (yes/no) W1 (ext. with load)*: 0.85 0.50 0.49 0.05 0.71 (0.49–0.92) 0.70
W2 (in rest): 0.83 0.75 0.13 0.17 0.31 (−0.03–0.39) 0.66
W3 (ext. without load)*: 0.83 0.52 0.40 0.02 0.65 (0.41–0.88) 0.66
Scapular observation (yes/no) Pseudo-winging* 0.78 0.59 0.28 0.12 0.47 (0.18–0.75) 0.56
Margo medialis winging 0.76 0.67 0.20 0.15 0.25 (−0.07–0.57) 0.54
Winging AND pseudo- winging 0.85 0.82 0.10 0.05 0.17 (−0.24–0.59) 0.70
Elevated/Depressed (maximally elevated)α 0.95 - 0.02 0.05 - -
Protractedα,∞ 1.00 - 0.00 0.00 - -
Upward rotationα,∞ 1.00 - 0.00 0.00 - -
Margo medialis rotation 0.93 0.93 0.04 0.02 −0.03 (−0.08–0.02) 0.86
SD standard deviation, ICC intra-class-correlation coefficient, CI confidence interval, SEM standard error of measurement, MDC minimal detectable change, CM centimeter, % percentage, W winging, EXT extension, PABAK
prevalence-and-bias-adjusted kappa.
α
No observations made by both testers.
∞
Statistics not possible because either A and/or B are constants.
A negative Kappa means that the two observers agreed less than would be expected just by chance.
*Significant inter-tester differences.
PHYSIOTHERAPY THEORY AND PRACTICE
9
10 C.M.LARSEN ET AL.
Dynamic test assessment methods (five) reposition error, Scapular upward rotation, Maximum
shoulder internal rotation, and Scapular observation
For the two test assessment methods measured in
including multiple categories did not show satisfactory
degrees (i.e. Initial scapular movement and Maximum
reliability.
passive shoulder internal rotation), ICC was 0.47 and
0.53 (‘poor’ to ‘moderate’), respectively, with SEM esti-
mates of 6.14 and 9.05 degrees, and MDC of 17.01 and Static scapular test assessment methods (two)
25.09 degrees, respectively. The MDC% corresponds to
The inter-rater reliability of the two static test assess-
25.4 and 15.50% and 427.7%, respectively (Table 5). For
ment methods (i.e. lower horizontal distance, upper
the one assessment methods measured in cm (i.e.
horizontal distance) was found to be moderate and
Proprioception/reposition error), ICC was 0.47
good, respectively. The current inter-rater reliability
(‘poor’), with SEM and MDC of 4.60 cm and
estimates of the Lower horizontal distance are lower
12.75 cm, respectively. The MDC% corresponds to
than previously reported on intra-rater reliability
99.9% (Table 5).
(ICC 0.91) (Juul-Kristensen et al., 2011) and (ICC
Observed agreement for the two dichotomous test
0.79–0.92) (Lewis and Valentine, 2008). As shown
assessment methods (i.e. Winging scapula and Scapular
in the Bland–Altman plot, the quite large average
observation), ranged from 76% to 100%. The lowest
discrepancy (approximately 0.80 cm) between the
and absent Kappa values were found in the Scapular
two raters may be a contributing factor. The current
observation method (elevated, protracted, upward rota-
measurements between the inferior angle of the sca-
tion). Statistical between-rater differences were found
pula and the corresponding spinous process (lower
in both test assessment methods. The reliability of
horizontal distance) is also included in a previous
Winging scapula varied from k: 0.31 to 0.71 (95% CI:
assessment method, the Lateral Scapular Slide Test
−0.03 to 0.92), indicating ‘fair’ to ‘substantial’ agree-
(LSST) first test position (Kibler, 1998). However, in
ment (Table 5). In all but three measures of the
this study, only unilateral measurements were taken.
Scapular observation method, it was not possible to
The Kibler test has shown similar inter-rater reliabil-
perform the statistical calculations due to an absence
ity (Nijs, Roussel, Vermeule, and Souvereyns, 2005;
of values in either Rater A or B. The calculated relia-
Odom, Taylor, Hur, and Denegar, 2001; Shadmehr,
bility ranged from k: −0.034 to 0.47 (95% CI: −0.08-
Bagheri, Ansari, and Sarafraz, 2010), but also better
0.75) (‘poor’ to ‘moderate’), with a negative value indi-
reliability has been reported when compared to the
cating less agreement than would be expected. The
current results (Curtis and Roush, 2006; Shadmehr
prevalence index of Winging scapula and Scapular
et al., 2016). Differences in design (i.e. training and
observation ranged from 0.04 to 10.49, (lowest in
clinical experience among raters), and measurement
Scapular observation), whereas the bias index ranged
equipment used (i.e. caliper versus tape measure)
from 0.00 to 0.17 (highest for Winging scapula).
may be the reasons, where the caliper measurement
Cohens kappa and Prevalence-And-Bias-Adjusted-
seems more precise.
Kappa (PABAK) improved reliability for most mea-
The current inter-rater reliability of the Upper hor-
sures, now ranging from k: 0.66 to 0.70, corresponding
izontal distance is similar to most measures in
to overall ‘substantial’ reliability for Winging scapula,
a previous study, reporting on bilateral shoulder assess-
with k: 0.54 to 0.86, ‘moderate’ to ‘almost perfect’
ments from both healthy and symptomatic shoulders
reliability for Scapular observation (Table 5). Table 6
(ICC 0.89–0.97) (Lewis and Valentine, 2008). Though,
presents the relative estimates and CIs for the WING
measurement errors were somewhat higher in the cur-
and No-WING groups (ICC, Kappa, 95% CI).
rent study (SEM 0.30–0.50 cm vs. 0.67 cm). Differences
in intra- and inter-rater assessment most likely
accounts for the variation in study findings.
Discussion
In a population of overhead sports participants with
Semi-dynamic scapular test assessment methods
and without scapular dyskinesis, 4 of 10 scapular test
(three)
assessment methods showed satisfactory inter-rater
reliability (i.e. Upper horizontal distance, Lower hori- Two of the three semi-dynamic test assessment meth-
zontal distance at max shoulder flexion, Acromial dis- ods (Lower horizontal distance at maximum shoulder
tance, and Winging scapula). The remaining scapular flexion and Acromial distance, rest/retraction) showed
test assessment methods, such as Lower horizontal dis- good (ICC 0.89) and good to excellent reliability (ICC
tance, Initial scapular movement, proprioception/ 0.82–0.92), respectively. Though, the last method
Table 6. Relative inter-rater reliability of the 10 clinical scapular test assessment methods: distributed into three categories: 1) Static
positioning assessment methods (n = 2); 2) Semi-dynamic positioning assessment methods (n = 3); and 3) Dynamic functional
assessment methods (n = 5) for the WING and No-WING groups.
WING No WING
(n = 22) (n = 19)
Test assessment methods ICC (95% CI) ICC (95% CI)
Lower horizontal distance (cm) 0.63 (0.10–0.85) 0.78 (0.42–0.91)
Upper horizontal distance (cm) 0.70 (0.27–0.88) 0.85 (0.62–0.94)
Lower horizontal distance, max flexion (cm) 0.81 (0.55–0.92) 0.95 (0.86–0.98)
Acromion – wall, rest 0.89 (0.73–0.95) 0.71 (0.46–0.85)
Acromion – wall, retract. 0.81 (0.53–0.92) 0.72 (0.41–0.88)
Scapular position, at rest 0.32 (−0.63–0.72) −0.18 (−2.05–0.55)
Scapular position, at 45° 0.01 (−1.40–0.59) 0.61 (−0.01–0.85)
Scapular position, maximal shoulder abduction 0.35 (−0.58–0.73) 0.35 (−0.68–0.75)
Dynamic functional assessment:
Initial scapular movement (°) 0.53 (−0.13–0.81) 0.34 (−0.71–0.75)
Proprioception\reposition error (cm) 0.63 (0.12–0.85) 0.75 (0.35–0.90)
Maximum passive shoulder internal rotation (°) 0.45 (−0.33–0.78) 0.61 (−0.02–0.85)
Kappa (95% CI) Kappa (95% CI)
Winging scapula (yes/no)
W1 (ext. with load): 0.52 (0.16-0.89) 0.88 (0.66-1.00)
W2 (in rest)∞: 0.35 (-0.03-0.73) -
W3 (ext. without load): 0.46 (0.09-0.82 0.86 (0.58-1.00)
Scapular observation (yes/no)
Pseudo-winging 0.44 (0.07-0.81) 0.35 (-0.17-0.86)
Margo medialis winging 0.05 (-0.16-0.45) 0.50 (0.04-0.95)
Winging AND pseudo-winging –0.10 (–0.2-0.00) 0.46 (–-0.14-1.00)
Elevated/Depressed (maximally elevated)∞
Protracted∞ - -
Upward rotation∞ - -
Margo medialis rotation∞ –0.05 (–0.12–0.02) -
ICC intra-class-correlation coefficient, CI confidence interval, % percentage, CM centimeter, W winging, EXT extension.
∞
Statistics not possible because either A and/or B are constants.
A negative Kappa means that the two observers agreed less than would be expected just by chance.
(Acromial distance) shows wider CIs when scapula is in to be good to excellent (ICC 0.81–0.96) (Johnson,
a retracted position. McClure, and Karduna, 2001; Watson, Balster,
For Lower horizontal distance at maximal shoulder Finch, and Dalziel, 2005). Reasons may be due to
flexion, no comparative reliability results are available. different study designs (inter-rater vs. intra-rater),
However, a previous study measured the distance from inappropriate time intervals between repeated intra-
the inferior angle of the scapula and the closest spinous rater measurements (Watson, Balster, Finch, and
process in the same horizontal plane at 180° of abduc- Dalziel, 2005), as well as a modified use of inclin-
tion in the scapular plane (Modified Lateral Scapular ometer measurements (Johnson, McClure, and
Slide Test), and found lower estimates of inter-rater Karduna, 2001).
reliability (ICC 0.58), in addition to larger levels of The current good to excellent reliability of Acromial
SEM (0.71 vs. 1.18 cm) and MDC (1.96 vs. 3.27 cm) distance, a measure of forward shoulder protraction
(Struyf et al., 2009). Differences in study design and test (distance between posterior border of the acromion
assessment methods may explain these discrepancies. and the wall), was higher than previous findings of
The more detailed and direct assessments of only moderate reliability (Struyf et al., 2009). Also, the
Scapular upward rotation at five different shoulder current estimates of SEM (0.69–1.05 vs. 1.36–1.70 cm)
positions showed poor reliability. This is in line with and MDC (1.92–2.90 vs. 3.77–4.71 cm) were slightly
a recent study on inter-rater reliability in asympto- better than previously reported (Struyf et al., 2009).
matic middle-aged women with a low presence of Reasons for the current improved reliability may be
scapular dyskinesis (De Groef et al., 2017), which the design using a 50/50 distribution of subjects with
also reported poor reliability (ICC 0.21–0.39). On and without scapular dyskinesis, as recommended for
the contrary though, other intra-rater reliability stu- reliability studies (Patijn and Remvig, 2007) and the
dies on the same assessment method found reliability standardized procedures
Dynamic scapular test assessment methods (five) current modifications was to be able to compare the
current Scapular observation method more precisely
The current inter-rater reliability for three of the five
with the Winging scapular assessment method
dynamic test assessment methods, including continu-
ous scores (i.e. Initial scapular movement,
Proprioception/reposition error and Maximal passive
Limitations and strengths
shoulder internal rotation), was low, with wide CIs
and high measurement errors. These results are in The current study has some limitations. The criterion
line with a previous study on intra-rater reliability on for being classified into either winging or no-winging
the same variables (ICC 0.73–0.76) (Juul-Kristensen was based upon a pre-screening evaluation, to ensure
et al., 2011). The current low reliability of the a satisfactory prevalence of the index condition of
Maximum passive shoulder internal rotation is some- scapular dyskinesis. However, for the dynamic test
what lower than previously reported, which may be due assessment methods with dichotomous scores, the
to different designs (inter-rater vs. intra-rater), varying recommended prevalence of 50/50 distribution of par-
participant positions, and use of measurement instru- ticipants with and without scapular winging (Patijn and
ments (Cools et al, 2014; van de Pol, van Trijffel, and Remvig, 2007) could naturally not be accomplished in
Lucas, 2010). all assessment categories, which is why PABAK was
Furthermore, in the two test assessment methods a valid alternative to the original kappa values.
including visual observations of the scapula in resting Secondly, due to an unintended error, there are
position, during active unloaded and loaded upper missing data from approximately half of the partici-
extremity movements (i.e Winging scapula and pants on the DASH score; however, equally distributed
Scapular observation), the highest inter-rater reliability in each group. Since the focus of this study was on
was found in the Winging scapula assessment method. reliability and not the relationship between assessment
This result is somewhat lower than previously reported scores and shoulder disability, this would seem to only
for intra-rater reliability (k 0.84–1.00) (Juul-Kristensen minimally affect our findings. The current data were
et al., 2011), but similar or higher than in previous collected from overhead sports participants only. This
studies also including scapular test assessment methods may limit the external validity to the more general
with few categories of visual scapular observations population. However, when testing reliability of clinical
mostly dichotomous, positive yes/no (k 0.41–0.61) assessment methods both individuals with and without
(McClure et al., 2009; Uhl, Kibler, Gecewich, and the study characteristics must be included. So as over-
Tripp, 2009). head sports participants have high prevalence of scap-
The current low inter-rater reliability for the Scapular ular dyskinesis it was obvious to select this group for
observation method, including multiple categories the current study. Further, as scapular dyskinesis is
(seven categories each with dichotomous scoring), was present in the general population as well, the current
somewhat similar to other findings supporting the use of reliability results are useful for clinical practice to
fewer categories of scapular observations during testing a large extent.
for improving reliability (Struyf et al., 2009). Of note, the The main strength of this study is its methodolo-
current Scapular observation method, originally gical approach, using a three-phased protocol as
described by Struyf et al. (2009), was modified so that recommended (Patijn and Remvig, 2007), including
scapular observations were performed from behind only blinding and randomization of raters in order to
during active loaded movements of the upper extremi- minimize bias. Another strength is the extensive and
ties. Further, evaluation of scapular position during rest transparent statistics, including raw data for interpre-
was performed only once in the current study compared tation (Mokkink et al., 2010; Sim and Wright, 2005).
to three times in the study by Struyf et al. (2009). Also, Also for transparency reasons, relative reliability
the current Scapular observation method was further results for the WING and no-WING groups, respec-
modified to include scapular evaluation during loaded tively, are presented. Although some group differ-
upper extremity movements in flexion/extension com- ences are displayed, especially for the agreement
pared to a previous test description using scapular eva- measures of the categorical data, a consistent pattern
luation during upper extremity movements in both of lower reliability for the WING group is not pre-
flexion and abduction (McClure et al., 2009). Finally, sent, which is often the case. However, reducing the
the current test assessment procedure for the Scapular study population to 22 and 19 participants, respec-
observation method was thoroughly described, including tively, in each group compromises the aim and
the number of test repetitions. The reason behind the design of our study. The study design that we
followed requires 40 participants in the study phase and quantitative distance measurements have better
presenting with various degrees of the index condi- reliability between clinicians compared to more com-
tion that we actually examined (scapular variation). plex measurements and may be better suited for use in
Therefore, group results are presented for transpar- clinical practice. Future research should focus on dis-
ency only. Lastly, this is the first study to include criminative validity and responsiveness of these four
a population, which is selected on the basis of the test assessment methods, while the use of the remaining
presence or absence of the index condition scapular six methods, should be conditioned on the preceding
dyskinesis, thereby avoiding most of the bias in kappa improvement of standardization.
statistics.
Acknowledgments
Research and clinical implications
We would like to acknowledge the Physical therapists and the
As stated in the introduction a knowledge gab still students who participated in recruitment, and adjustment of
remains as to whether or not scapular dyskinesis may the test assessment protocol. A special thanks to the Physical
directly cause, contribute to, or be the result of, therapist involved in data collection, for their dedicated work.
shoulder symptoms, since dyskinesis also exists in
asymptomatic shoulders (McQuade, Borstad, and De
Oliveira, 2016; Plummer et al., 2017). Therefore, this Disclosure statement
area requires further investigation. The present study The authors report no declarations of interest.
provides clinicians with simple and reliable methods for
the assessment of the scapular position and function in
sagittal, frontal, and horizontal planes of reference. The ORCID
assessment methods which in this study displayed satis- Camilla Marie Larsen http://orcid.org/0000-0003-4691-
factory reliability were simple quantitative distance 3609
measurements and a simple observational method
including few scoring categories. In line with previous
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Appendix 1. Protocol including descriptions and criteria for 10 clinical scapular test assessment
methods evaluating the positioning and function of the scapular
The assessments are carried out when the subject is appropriately undressed and barefoot. The results are observed and recorded
on the rater’s assessment sheet (Appendix 2). The test subject is directed by a third subject to not talk during the test.
Clinical test assessment method Position and movement of the test subject
Lower horizontal distance/Upper horizontal distance) (cm) (Standing) The test subject stands in a normal anatomical position with arms relaxed by
The rater tells the test subject to do the following: their sides, in the position s/he has naturally put them. The subject breathes
“Stand here on the cross and look straight ahead with your arms by your deeply into the abdomen, so that scapula movement is minimized.
sides. I am going to feel your back and mark some points and measure the
distance between the points.”
The rater stands behind the test subject and performs the test.
a) The inferior angle of the scapula is palpated, and the point is marked.
b) The medial end of the scapular spine is palpated, and the place is
marked by small stickers, because these will not leave marks.
The distance from 1) the medial end of the scapular spine and 2) the
inferior angle of the scapula perpendicular to the spinous process is
measured unilaterally (cm).
Use a tape measure to measure the distance.
The results are recorded.
Lower horizontal distance, max shoulder flexion (cm) (Standing) The subject flexes their arm to the maximum and keeps it there.
“Now extend your arm forwards and upwards as high as possible and hold
the position while I take the measurement.”
The inferior angle of the scapula is palpated. The distance from the
inferior angle of the scapula perpendicular to the spinous process is
measured unilaterally (cm).
Use a tape measure to measure the distance.
The results are recorded.
Acromial distance (cm) (standing) The subject stands against a wall in a normal anatomical position, with their
a) The rater demonstrates and explains the following: “Now put your back arms by their sides; in the position the subject has naturally put them. Both
against the wall, so that your heels and the upper back touch the wall. heels and the upper back touch the wall. The feet are placed shoulder-width
Stand as you normally would.” apart.
The rater palpates the rear edge of the acromion (the corner), which is
marked. Using a pointed calliper, the distance is measured perpendicular
to the wall. The results are recorded.
b) The rater explains: “Now stand up straight, pull your shoulders back and
slightly downwards towards your lower back. You must hold this position
until I tell you.”
The rater ensures that the subject adopts – what is for that subject – an
upright position, and the scapula is, as far as possible, placed in neutral
(scapula setting). The rater asks the subject to hold their shoulders in the
adopted position while the measurement is taken. The arms hang by their
sides.
The distance measurement is repeated, i.e. the rater palpates the
posterior part of the acromion (the same point as before) and, using The subject is still standing against the wall, in the same position as
a pointed caliper, measures the distance perpendicular to the wall. The described above.
results are recorded. The subject performs a retraction movement, and makes a slight depression
of both scapula, i.e. the subject “stands up straight”.
The neck is held straight and lengthened, and the heels and upper back are
in as much contact with the wall as possible.
(Continued )
(Continued).
Scapula upward rotation (°) (standing) The subject stands facing a line of tape in a normal anatomical position with
a) The rater demonstrates and explains the following: “Now stand on the feet shoulder-width apart. The dominant/affected arm is tested. The test
cross and take a deep breath. Then stand normally. Your arms should be subject takes a deep abdominal breath and places their arms fully extended
straight and turned so your thumbs point up toward the ceiling.” by the sides in an outwardly rotated position.
From this position, the rater measures the abduction angle (relative to the
vertical plane) of the humerus at rest, with the first inclinometer
positioned, using Velcro, perpendicular to the humerus, just above the
lateral epicondyle.
The scapula rest position is also measured, using the second inclinometer,
which is manually positioned relative to the scapular spine’s longitudinal
direction (relative to the horizontal plane).
The inclinometers are set such that 0° corresponds to the vertical line/
horizontal plane.
b) The rater continues to explain: “When I tell you, slowly lift your arms
toward the ceiling with your thumbs pointing up and I want you to stop
a few times on the way up, while I make a note of some measurements.”
The rater maintains the position of the inclinometer along the scapular
spine with his/her thumb and forefinger and, optionally, orients him/ The subject stands in the same starting position as above and is directed to
herself in relation to the medial border and acromion with the middle and perform abduction with instructions from the rater to stop four times during
ring fingers. The angle is measured relative to the horizontal plane, while the process, where the rater will note the four measurements.
the test subject abducts the arm and is instructed to stop at 45°, 90°, 135°,
and at maximum abduction.
Initial scapular movement (°) (Sitting) The subject sits in a natural, upright position (not overly adjusted), with
The rater palpates the rear corner of the acromion and the lateral arms by their sides, placed in the position the test subject naturally puts
epicondyle of the humerus and draws a line between the points. The them.
distance is measured and the midpoint is marked. The shoulder is flexed slowly on command and, on the command “stop”, the
The inclinometer, to be used later, is put on this midpoint, flush with the movement is kept static.
line between the acromion and epicondyle.
The rater explains the following: “Please sit upright, look straight ahead,
with your arms by your sides. When I tell you, begin to lift your arms slowly
directly in front of you, with your thumbs pointing up, and when I say stop,
hold your arms at that height.”
The rater sits behind the test subject. The inferior angle of the scapula is
palpated and the rater places his/her fingers on the lateral and medial
side of the inferior angle of the scapula. This can be felt when the scapula
moves in a continuous movement to the side.
When the scapula begins to move as described, the rater says “stop”.
To ensure that the scapula moves in a continuous motion, the rater keeps
his/her free hand on the test subject’s arm, and guides the arm in small
movements around the point where the scapula moves.
The angle between the upper arm and the frontal plane is measured. The
angle is measured using an inclinometer. The result is recorded.
Proprioception\reposition error (cm) (sitting) The subject sits upright, and their back is supported. Their feet are fully
The subject is instructed as follows: “Please sit upright with your lower back supported by being flat on the floor, and their arms are relaxed by their
supported. You should be able to have your feet flat on the floor.” sides. The upper body is aligned so that the scapula is in a natural/easy,
A laser pointer is fixed to the shoulder, parallel to the lateral edge of the retracted position (scapula setting).
acromion (directly below). The laser pointer is switched on and pointed The test subject is first instructed to remember the position of the relevant
directly into the center of a target that is positioned on the wall two shoulder and then roll that shoulder at a moderate speed while blindfolded.
meters away from the subject. (The target is positioned after the laser has Then the subject has to return the shoulder to the previous position as best
been fixed to the test subject’s shoulder in such a way that the laser is as s/he can. The test subject can have one go before the go where the
centrally positioned.) measurement is taken.
The subject is instructed further: “Now try to be aware of and remember
the position your shoulders are in. With a blindfold on, roll one shoulder
backwards, but not too slowly. Once you have done this, you should try and
regain the position you had before. You may make the movement once
before the measurement is taken.”
The distance between the mark made by the laser pointer and the center
of the target is measured (cm).
(Continued )
(Continued).
Maximum passive shoulder internal rotation (°) (standing) The subject stands with arms relaxed by their sides. The dominant/affected
The subject is instructed as follows: “Now lift your arm out to the side with arm is tested.
your thumb pointing up until it is completely horizontal, then bend your
elbow so your hand/fingers point up towards the ceiling. On my command,
I will help you to rotate the forearm downward as far as it will go.”
The upper arm is abducted to 90° and, with the support of the rater, the
elbow is flexed to 90°. The inclinometer is placed at the midpoint of the
forearm. The rater passively rotates the upper arm inwardly, without
fixing the scapula, until there is passive tissue resistance. The angle
between the forearm and the vertical line is measured (degrees).
Winging – extension with 1.5 kg weight (yes/no) (standing) The subject does the self-test as shown and explained by the rater. The
a) The rater demonstrates how the test is performed and explains the subject should stand with their back to the rater and look straight ahead.
following: The arms are lifted in full flexion with hands grasping the dumbbells, which
“Stand on the cross and look straight ahead. With a dumbbell in each hand, are placed in a horizontal position for flexion/extension. The test subject lifts
lift your arms as high as you can over your head with straight arms. You a hand weight of 1.5 kg. With the elbows extended, the subject slowly
should then lower them slowly down with your arms straight in front of lowers both arms down in the direction of extension to neutral. The
you.” movement should be slow and controlled. The movement is repeated one
The rater stands behind the subject and observes the scapula movement more time.
when the arms are extended from full flexion. No measuring instruments
are used, but a visual evaluation is made.
The rater assesses whether or not the subject has dyskinesis (visible
medial border and/or inferior angle of the scapula). If in doubt, no
dyskinesis is recorded.
Winging – at rest (yes/no) (standing) The subject stands in a normal anatomical position with arms relaxed by
The following explanation is given: “Please continue to look straight ahead their sides, placed in the position the subject naturally adopts.
and just relax and stand as you would normally stand.” (Picture; same subject position as Lower horizontal distance)
The rater observes the scapula while the subject is at rest.
At no time should the rater correct the subject’s posture.
No measuring instruments are used, but a visual evaluation is made.
The rater assesses whether or not the subject has dyskinesis (visible
Winging – extension without the use of weights (yes/no) (standing) The subject performs the test him/herself as shown and described by the
The rater demonstrates and explains: rater.
“Now lift your arms as high as you can. Then lower them slowly back down. The subject stands with their back to the rater and looks straight ahead.
Your arms should be extended directly in front of you with your thumbs The arms are lifted in full flexion with the thumbs pointing up.
pointing up.” The subject lowers both arms slowly in the direction of extension to neutral.
The rater stands behind the subject and observes the scapula movements. This is done with the arms straight.
No measuring instruments are used, but a visual evaluation is made. The movement should be slow and controlled.
The rater assesses whether or not the subject has dyskinesis (visible The movement is repeated one more time.
(Continued )
(Continued).
Scapular observation (yes/no) The test subject stands in a normal anatomical position, with arms by their
The rater explains and demonstrates the following: “Stand on the cross sides, outwardly rotated, (thumbs towards the ceiling), with a 1 kg weight in
and look straight ahead with your arms by your sides and hold a 1 kg each hand and feet shoulder-width apart.
weight in each hand. When I tell you, start to slowly lift your arms in front of The test subject takes an initial deep abdominal breath. The subject is
you as high as you can and then back down. It should take five seconds to instructed to slowly inflect and extend both arms at a pace controlled by
raise them and five seconds to lower them. Your arms should be straight a metronome. Each flexion and extension movement should last five
and turned outwards so that the weights point up toward the ceiling. The seconds. The movement is carried out five times.
movement will be repeated five times and I will stand behind you.”
The rater stands behind the test subject and observes any abnormal
movement or position of the scapula on the dominant or affected side. If
an abnormality/asymmetry occurs, this is marked on a standardized
assessment sheet. If the rater is in doubt, the movement/position is
recorded as ‘normal’.
Appendix 2. Assessment sheet for 10 clinical scapular test assessment methods evaluating the
positioning and function of the scapula
Name: __________________________ Date:__________________________
Subject ID:______________ Raters´ name:_____________________
Test round:____1 2 3__________ (circle the appropriate #) Time of day:_____________________
Lower horizontal distance / Upper horizontal distance (cm) (Standing)

The inferior angle of the scapula, the medial end of the scapular spine, and the perpendicular points on the spine are marked.
The distance is measured using a tape measure:
“Stand here on the cross and look straight ahead with your arms by your sides. I am going to feel your back and mark some
points and measure the distance between the points.”
Dominant/affected side
Test round 123
Distance (cm) from the inferior angle of the scapula to the perpendicular point on the spine (point a)
Distance (cm) from the medial end of the scapular spine to the perpendicular point on the spine (point b)
Lower horizontal distance, max shoulder flexion (cm) (Standing)

Distance from the inferior angle of the scapula to the perpendicular point on the spine (point a)
“Now extend your arm forwards and upwards as high as possible and hold the position while I take the measurement.”
Test round 123
Distance (cm) from the inferior angle of the scapula to the perpendicular points on the spine (point a)
Acromial distance (cm) (Standing)

a) The test subject stands with both heels and upper back against the wall.
The distance from the posterior part of the acromion perpendicular to the wall is measured using a pointed calliper: “Now put
your back against the wall, so that your heels and the upper back touch the wall. Stand as you normally would.”
Test round 123
Distance (cm) from the acromion to the wall
b) The test subject stands with both heels and upper back against the wall. The shoulders are retracted but the upper arms
should still be flush with the trunk. The distance from the posterior part of the acromion perpendicular to the wall is measured
using a pointed calliper: “Now stand up straight, pull your shoulders back and slightly downwards towards your lower back.
You must hold this position until I tell you.”
Test round 123
Distance (cm) from the acromion to the wall
Scapula upward rotation (°) (Standing)

The test subject performs abduction and the rotation of the scapula is measured at rest, at 45°, 90°, 135° and at maximal
abduction, using a inclinometer held on the lateral border of the scapular spine. The rater demonstrates and explains the
following: “Now stand on the cross and take a deep breath. Then stand normally. Your arms should be straight and turned so
your thumbs point up toward the ceiling.”
Second part: The rater continues to explain: “When I tell you, slowly lift your arms toward the ceiling with your thumbs
pointing up and I want you to stop a few times on the way up, while I make a note of some measurements.”
Test round 123

Humeral movement (degrees) Humerus abduction angle Rotation of the scapula (degrees)
At rest
45°
90°
135°
Maximum abduction
Initial scapular movement (°) (Sitting)

The rater palpates the inferior angle. The test subject slowly flexes the arms.
When the scapula moves with the arm movement, the angle between the midpoint on the upper arm and the vertical line is
measured using an inclinometer: “Please sit upright, look straight ahead, with your arms by your sides. When I tell you, begin
to lift your arms slowly directly in front of you, with your thumbs pointing up, and when I say stop, hold your arms at that
height.”
Test round 123
The angle (degrees) between the upper arm and the vertical line
Proprioception\reposition error (cm) (Sitting)

The subject sits upright and the back is supported. The feet are fully supported by being flat on the floor, and arms are relaxed
by their sides. The upper body is aligned so that the scapula is in a natural/easy, retracted position (scapula setting):“Please sit
upright with your lower back supported. You should be able to have your feet flat on the floor.”
The rater positions a laser pointer, switches it on and points it directly into the centre of a target two metres away. The subject
performs a backwards shoulder roll with their eyes closed. Then the subject has to try to regain the same shoulder position as
before. The distance from the point of the laser beam and the middle of the target is measured (cm): “Now try to be aware of,
and remember, the position your shoulder is in. With a blindfold on, roll one shoulder backwards, but not too slowly. Once
you have done this, you should try and regain the position you had before. You may make the movement once before the
measurement is taken.”
Test round 123
Distance from the point of the laser beam to the middle of the target (cm)
Maximum passive shoulder internal rotation (°) (Standing)

The subject’s upper arm is abducted to 90° and, with the support of the rater, the elbow is flexed to 90°. The inclinometer is
placed at the midpoint of the forearm. The rater passively rotates the upper arm inwardly, without fixing the scapula, until
there is passive tissue resistance. The angle between the forearm and the vertical line is measured (degrees): “Now lift your
arm out to the side with your thumb pointing up until it is completely horizontal, and then bend your elbow so your
hand/fingers point up towards the ceiling. On my command, I will help you to rotate the forearm downward as far as it will
go.”
Test round 123
The angle (degrees) between the forearm and the vertical line
Winging - extension with 1.5 kg weight (yes/no) (Standing)

The subject lifts their arms as high as possible with 1.5 kg weights in each hand. The scapular is evaluated in relation to visible
medial border or inferior angle, by an arm extension from full flexion with the thumbs pointing upward. Visual estimate. If
there is doubt, no dyskinesis/no is recorded: “Stand on the cross and look straight ahead. With a dumbbell in each hand, lift
your arms as high as you can over your head with straight arms. Then lower them slowly down with your arms straight in
front of you.”
Test round 123
Visual estimate: visible medial border, visible inferior angle or both (yes/no)
Visible medial border (put an ’x’ in the box)
Visible inferior angle (put an ’x’ in the box)
Winging – at rest (yes/no) (Standing)
The subject stands at rest with arms by their sides. The scapula is evaluated in relation to visible medial border or inferior
angle. Visual estimate. If in doubt, no dyskinesis/no is recorded: “Please continue to look straight ahead and just relax and
stand as you would normally stand.”
Test round 123
Winging - extension without the use of weights (yes/no) (Standing)

The subject lifts their arms as high as they can. The scapula is evaluated in relation to visible medial border or inferior angle.
Visual estimate. If in doubt, no dyskinesis/no is recorded:
“Now lift your arms as high as you can. Then lower them slowly back down. Your arms should be extended directly in front of
you with your thumbs pointing up.”
Test round 123
Scapular observation (yes/no) (Standing)
Five repetitions of maximal shoulder flexion/extension (180°) at a standard speed, with a 1 kg weight. There are six boxes to
mark. The rater explains and demonstrates the following: “Stand on the cross and look straight ahead with your arms by your
sides and hold a 1kg weight in each hand. When I tell you, start to slowly lift your arms in front of you as high as you can and
then back down. It should take five seconds to raise them and five seconds to lower them. Your arms should be straight and
turned outwards so that the weights point up toward the ceiling. The movement will be repeated five times and I will stand
behind you.”
Visual estimate. If in doubt, no dyskinesis/no is recorded. You may mark more than one box.
Test round Visual estimate (yes/no) 123
Tilting and/or Winging Winging Elevation Protraction Upward Rotation
Winging (put an and Scapula Medial rotation Medial border is not parallel
Inferior angle visible x......) Tilting clearly border Scapula to the lumbar spine
or medial border (put an x) elevated/ visible in a rotates with (at rest)
visible Tilting depressed translational the first 60°
(put an movement of flexion
x......)

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Physiotherapy Theory and Practice

An International Journal of Physical Therapy

ISSN: 0959-3985 (Print) 1532-5040 (Online) Journal homepage: https://www.tandfonline.com/loi/iptp20

Clinical assessment methods for scapular

To link to this article: https://doi.org/10.1080/09593985.2019.1579284

Published online: 29 Mar 2019.

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Clinical assessment methods for scapular positioning and function. An inter-

ABSTRACT ARTICLE HISTORY

Introduction (Comerford and Mottram, 2001; Kibler and McMullen,

7) Proprioception\reposition Active proprioception/reposition error of the scapula during scapular setting,

Table 2. Contingency tables with findings from Rater A and Rater B.

Winging scapula (yes/no)

W1 (ext. with B W2 (rest) B W3 (ext. B

Scapular observation (yes/no)

Pseudo- B Winging B Winging & B

Elevated/ B Protracted B Upward B

Static positioning assessment

Semi-dynamic positioning assessment

Dynamic functional assessment

Name: __________________________ Date:__________________________

Subject ID:______________ Raters´ name:_____________________

Test round:____1 2 3__________ (circle the appropriate #) Time of day:_____________________

Lower horizontal distance / Upper horizontal distance (cm) (Standing)

Lower horizontal distance, max shoulder flexion (cm) (Standing)

Acromial distance (cm) (Standing)

Scapula upward rotation (°) (Standing)

Test round 123

Initial scapular movement (°) (Sitting)

Proprioception\reposition error (cm) (Sitting)

Maximum passive shoulder internal rotation (°) (Standing)

Winging - extension with 1.5 kg weight (yes/no) (Standing)

Winging - extension without the use of weights (yes/no) (Standing)

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Name: Date:

Subject ID: Raters´ name:_______

Test round:1 2 3 (circle the appropriate #) Time of day:_______________