PATIENTS WITH SHOULDER PAIN: STATE OF THE ART Jo Nijs, PhD, MSc, MT, PT, a Nathalie Roussel, PT, MT, b Filip Struyf, PT, c Sarah Mottram, MSc, d and Romain Meeusen, PhD, PT e I t is widely recognized that the ability to position the scapula at rest and during movements/tasks (scapular positioning) is essential for optimal upper limb func- tion. 1,2 Scapular positioning should be optimal in relation to both the thorax and the humerus. In relation to the humerus, optimal positioning is essential for appropriate positioning of the glenoid, which in turn guarantees mobility and stability of the glenohumeral joint. The simultaneous movement of the scapula and the glenohumeral joint is referred to as the scapulohumeral rhythm. A natural kinematic rhythm exists between gleno- humeral abduction and scapular upward rotation. According to de Groot, 3 the mean glenohumeral-to-scapular rotation ratio varied between 2.3 and 3.6 across different studies. The first phase of shoulder abduction (b608 and the final 408 of adduction) is characterized by a large glenohumeral- to-scapular ratio 4 ; the scapula makes small movements to position the glenoid adequately in relation to the humerus. The first phase is called the dsetting phase,T during which the scapula contributes very little to the range of motion. 5 During the second phase of shoulder abduction/adduction, the mean glenohumeral-to-scapular ratio in healthy should- ers is 2.4. 4 Faulty positioning of the scapula during movement is characterized by forward tilting and/or an abnormal kinematic rhythm between glenohumeral abduc- tion and scapular upward rotation. The muscular system is the major contributor to scapular positioning both at rest and during functional tasks. In the case of altered activity (delayed firing, inefficient recruitment, or increased tension and consequent shortening) of scapular muscles, scapular positioning is likely to become abnormal. Inappropriate control of scapular positioning has frequently been linked to shoulder and neck disorders. 6-9 Moreover, scientific evidence supporting abnormal scapular positioning in patients with shoulder impingement syndrome, 2 symptoms of shoulder impingement, 10,11 atraumatic shoulder instability, 12 multi- directional shoulder joint instability, 13 and shoulder pain after neck dissection in patients with cancer 14,15 is accumulating. One study has shown that physiotherapy (primarily exercise therapy targeting the scapulothoracic muscles) was superior over no treatment in patients with subacromial impingement syndrome. 16 Many strategies for the assessment of scapular position- ing are described in the scientific literature. However, most of these strategies apply expensive and specialized equip- ment (laboratory methods), making their applicability in clinical practice nearly impossible. From a clinical perspective, guidelines for a reliable and valid assessment of faulty scapular positioning in patients with shoulder pain are essentially lacking. There is a need to develop simple clinical indicators to allow clinicians to assess scapular kinematic behavior accurately. 2,5 These tests 69 a Assistant Professor, Division of Musculoskeletal Physiother- apy, Department of Health Sciences, University College Antwerp, Belgium; Assistant Professor, Department of Human Physiology and Sports Medicine, Faculty of Physical Education and Physi- otherapy, Vrije Universiteit Brussel, Belgium. b Teacher, Division of Musculoskeletal Physiotherapy, Depart- ment of Health Sciences, University College Antwerp, Belgium. c Teacher, Division of Musculoskeletal Physiotherapy, Depart- ment of Health Sciences, University College Antwerp, Belgium; Research Fellow, Department of Human Physiology and Sports Medicine, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Belgium. d Founding Director, Kinetic Control, Ludlow, Shropshire, United Kingdom. e Professor and department head, Department of Human Physiology and Sports Medicine, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Belgium. Submit requests for reprints to: Jo Nijs, PhD, MSc, MT, PT, Campus HIKE, Departement G, Hogeschool Antwerpen, Van Aertselaerstraat 31, B-2170 Merksem, Belgium (e-mail: j.nijs@ha.be). Paper submitted May 22, 2006; in revised form August 8, 2006; accepted August 24, 2006. 0161-4754/$32.00 Copyright D 2007 by National University of Health Sciences. doi:10.1016/j.jmpt.2006.11.012 should be affordable, easy to perform, reliable, valid, and responsive to change. The present article provides an overview of the clinical examination of scapular positioning in patients with shoulder pain. First, an overview of the observation of scapular positioning is provided. The outline should enable clinicians to identify faulty scapular positioning at rest and during movement. Second, an overview of the literature on clinical tests for the assessment of scapular positioning at rest and during movement is provided. The published data addressing the clinimetric properties of the tests is pre- sented, and suggestions for future research are provided. OVERVIEW OF SCAPULAR POSITIONING Observation of Static and Dynamic Scapular Positioning Observation of resting scapular position should be performed in the frontal and sagittal view, with the patient positioning both arms relaxed beside their body. At present, there is no consensus about the optimum resting scapular position; further study is warranted. 1 From the available literature, it can be concluded that the scapula (or the scapular plane) makes an angle of 308 in respect to the frontal plane, 3 the medial border of the scapula is positioned parallel to the spine (ie, the spinous processes of the thoracal spine), 17 the upper edge of the scapula should be located at the second or third thoracic vertebra (Th), the inferior angle at Th7-9, and the scapula of the dominant side is positioned lower and further away from the spine in com- parison to the nondominant side. 17 In addition, the inferior angle and medial border of the scapula should be flat against the chest wall, 1 the scapula should be positioned midway between medial and lateral rotation and midway between elevation and depression, and clinicians should be aware of potential asymmetric scapular positioning patterns (although minor differences are considered normal in respect to hand dominance). dScapular wingingT is often seen in patients with shoulder dysfunctions. It is important to make a distinction between dtrue wingingT and dpseudowinging.T True winging (medial border winging) is characteristic by an inefficient serratus anterior muscle (in some cases related to long thoracic nerve palsy) or spinal accessory nerve involvement. The latter might be a mononeuritis of the spinal accessory nerve or a consequence of neck dissection in head and neck cancer patients. In either case, it is characterized by a painless weakness of the trapezius muscle that results in slight limitation of active arm elevation and lateral gliding with concomitant lateral rotation of the scapula. 15 Pseudo- winging is characterized by a prominent inferior angle and indicates forward tilting of the scapula. It is often associated with downward rotation (ie, the scapula adopts a protracted and downwardly rotated position). Scapular winging (pseudowinging) is likely to increase anterior tipping of the scapula during humeral elevation in the scapular plane. Patients with (symptoms of) shoulder impingement syndrome, on average, have been shown to move the scapula toward a more anteriorly tipped position during humeral elevation in the scapular plane in comparison with asymptomatic subjects. 10,18 This pattern of faulty scapular dynamics may be related to a decreased action of the serratus anterior and lower trapezius muscle and would place the anterior acromion in closer proximity to the rotator cuff tendons and increase the potential for subacro- mial impingement. 10 Scapular winging might be related to and/or be more pronounced by poor posture characterized by anterior positioning of the head and shoulders. Indeed, evidence supportive of a relationship between posture, pectoralis minor muscle length, and scapular malpositioning has been provided. 19 A short pectoralis minor muscle length was related to increased scapular internal rotation and decreased scapular posterior tilting during arm elevation. Thoracic hyperkyphosis in sitting alters dynamic scapular position- ing: the acromion will be positioned lower, leading to diminished subacromial space 8 and consequent increased impingement risks. 20 The observation that a slouched sitting posture decreases posterior tipping and lateral rotation of the scapula during humeral elevation 20 supports this view. Contrary to this, other researchers were unable to find conclusive evidence supportive of interactions between scapular posture and subacromial impingement syndrome 21 and shoulder overuse injuries. 22 We conclude that clinicians should be aware of the potential influence of (scapular) posture on shoulder and scapula kinematics. This brings us to the observation of dynamic scapular positioning. To assess the kinematic rhythm between glenohumeral abduction and scapular upward rotation, Fig 1. The measurement of the distance between the posterior border of the acromion and the table surface with the patient relaxed. 70 Journal of Manipulative and Physiological Therapeutics Nijs et al January 2007 Scapular Positioning in Shoulder Pain clinicians observe scapular positioning during movement of the shoulder girdle (eg, shoulder abduction in the coronal plane). However, studies examining the reliability or validity of the observation of dynamic scapular positioning are essentially lacking. In absence of guidelines supported by research data of direct relevance to clinical practice, clinicians might consider the following issues. For a single shoulder girdle and for a constant movement velocity, the kinematic rhythm between glenohumeral abduction and scapular upward rotation does not appear to vary from 1 testing session to another, but left-right differences are considered normal. 4 Thus, clinicians should try to make sure that their patients perform shoulder abductions at the same velocity when observations of the dynamic scapular positioning pattern are performed. For interpretation of the scapular rhythm, clinicians can apply the movement pattern as described in the introduction section. Shoulder patients with a capsular pattern (capsular restrictions of joint mobility) typically present with the scapula contributing a great deal to the range of motion in the first part of shoulder abduction. 5,23 The addition of weights during shoulder movements has been suggested as a method to increase or reveal faulty scapular positioning patterns. 7 MEASUREMENT OF STATIC SCAPULAR POSITIONING The measurement of the distance between the posterior border of the acromion and the table was first described by Host. 6 The patient is positioned supine and instructed to relax. In this position, the assessor measures the distance between the posterior border of the acromion and the table bilaterally (measured vertically with a tape measure as displayed in Fig 1). Afterward, this procedure can be repeated with the patient actively retracting both shoulders. To achieve active bilateral shoulder retraction, the patient is instructed to actively move both shoulders toward the table surface. This measurement might reflect pectoralis muscle length or even forward tilting. The measurement of the distance between the posterior border of the acromion and the table displayed excellent interobserver reliability in patients with shoulder pain: the intraclass coefficients (ICCs) varied between 0.88 and 0.94 (relaxed) and between 0.91 and 0.92 for the measurement with active shoulder retraction. 24 When comparing the mean values between the symptomatic and the asympto- matic side, nearly identical results were obtained (F72 mm for the relaxed position and F48 mm for the retracted position). 24 This finding is in accordance with the observa- tions of Hebert et al, 2 who found that in patients with primary shoulder impingement syndrome, the 3-dimen- sional scapular behavior does not differ between the symptomatic and the asymptomatic side, but, in fact, both shoulders differ in respect to scapular behavior when compared with healthy subjects. If the measurement of the distance between the posterior border of the acromion and the table generates clinically important data, then the test should be able to differentiate between patients with primary shoulder impingement syndrome and healthy controls. However, recently published data question the validity of the measurement: it correlated poorly with the pectoralis minor muscle length measured using a Flock of Birds electromagnetic capture system. 19 The measure- ment performed with the patient in supine position may be biased because of the influence of the table on scapular position (the table is likely to dsetT the scapula in a correct position) and the alteration on the effect of gravity. 19 Therefore, it is suggested to perform the same measurement with the patient in standing position (ie, measure the horizontal distance between the posterior border of the acromion and the wall). This measurement has been found to display fair to good interobserver agreement (unpublished data) in a mixed sample of symptomatic and asymptomatic subjects, but validity data are currently unavailable. Further study is warranted. The measurement of the distance from the medial scapular border to the fourth thoracic spinous process was also first described by Host. 6 The test is performed in standing position with the patient instructed to stay relaxed. Both the fourth thoracic spinous process and the medial scapular border are identified through palpation. Previous research provided evidence supportive of the use of scapular skin surface palpation as a component of clinical tests: surface palpation of scapular position has been shown to be a valid method for determining the actual location of the scapula. 25 The distance between both anatomical landmarks is measured in the horizontal plane using a tape measure. Again, this procedure is repeated with the patient actively retracting both shoulders (Fig 2). To achieve active bilateral Fig 2. The measurement of the distance from the medial scapular border to the fourth thoracic spinous with active bilateral shoulder retraction. Nijs et al Journal of Manipulative and Physiological Therapeutics Scapular Positioning in Shoulder Pain Volume 30, Number 1 71 shoulder retraction, the patient is instructed to actively move both shoulders backward. Together with the initial description of the test, Host 6 provided a guideline for the interpretation of the test outcome: in normal subjects, the distance from the medial scapular border to the fourth thoracic spinous process should be 5.08 cm. However, the guideline was based on clinical observations rather than on experimental data. In our study, we found mean values of 6.15 cm (symptomatic side) and 6.00 cm (asymptomatic side). 24 The interobserver reliability for the test was too low (the ICCs varied between 0.50 and 0.79) when performed with the patient relaxed. A fair interobserver reliability was found (ICCs between 0.70 and 0.80) when the distance from the medial scapular border to the fourth thoracic spinous process with active bilateral shoulder retraction was measured. Others measured the distance from the medial scapular border to the third (not the fourth) thoracic spinous process. Evidence suppor- tive of intraobserver reliability (ICC = 0.91) and criterion validity (the clinical test outcome correlated with the measurement performed on a radiography; r = 0.57) has been provided. 26 The scapular distance is another test for the assessment of resting scapular position. The distance between the angulus acromion and the third thoracic spinous process is measured to determine the scapular distance. The distance is normal- ized by dividing it by the scapular length (ie, the distance between spina scapula, localized at the margo medialis, and the angulus acromion). 27 The measurement of both the scapular distance (ICC = 0.94) and the scapular length (ICC = 0.85) has been shown to have good to excellent intraobserver reliability in asymptomatic subjects. 27 Like- wise, the interobserver reliability in asymptomatic subjects was excellent (ICC between 0.91 and 0.92). 23 The scapular distance was not related to muscle strength of the pectoralis minor or trapezius muscle. 27 Finally, the Lennie test has been postulated to measure scapular resting position and has been found to have fair intertester reliability and criterion validity in relation to radiographic measurements. 17 Despite its undoubted value for biometric research, the Lennie test is time-consuming and complex, limiting its applicability in clinical practice. For these reasons, the interested reader is referred to the original manuscript. Measurement of Dynamic Scapular Positioning The lateral scapular slide test (LSST) was designed by Kibler 28 to assess scapular asymmetry under varying loads. The test performance has been repeatedly presented in the scientific literature. The interested readers are therefore referred to the relevant literature. 28-30 For interpreting the LSST, a side-to-side difference of 1.5 cm was originally suggested for the diagnosis of shoulder dysfunction. 28 Experimental data, however, indicated that a side-to-side difference of 1.5 cm is frequently observed in asymptomatic subjects, and that the threshold value of 1.5 cm has a low specificity in diagnosing shoulder dysfunctions. 29,30 In addition, the outcome of the LSSTwas unable to differentiate between the symptomatic and asymptomatic side. 24 For all 3 tests positions, we observed an acceptable to good interobserver reliability (ICC N 0.70). These results are not in accordance with 2 previous studies that found ICC values of 0.79, 0.45, and 0.57 for subjects with shoulder impairments 29 and even lower ICC values for asymptomatic subjects (ranging between 0.18 and 0.69) 23 and for junior elite swimmers (ranging between 0.20 and 0.82) 31 (Table 1). It is difficult to explain the differences in findings among various studies. Addressing the validity, Table 1. Overview of the reliability data of clinical tests for the assessment of scapular positioning Test Peterson et al 26 DiVeta et al 27 Gibson et al 23 Nijs et al 24 Odom et al 29 McKenna et al 31 Watson et al 32 Johnson et al 33 Posterior acromion, table relaxed 0.88-0.94 Posterior acromion, table retraction 0.92-0.91 Medial scapular border, T4 relaxed 0.50-0.79 Medial scapular border, T4 retraction 0.70-0.80 Medial scapular border, T3 .91 a LSST position 1 0.82-0.96 0.79 0.65-0.74 LSST position 2 0.85-0.95 0.45 0.79-0.82 LSST position 3 0.70-0.85 0.57 0.20-0.57 Scapular distance 0.94 a 0.91-0.92 Scapula upward rotation 0.81-0.94 a 0.89-0.96 a Unless indicated (superscript baQ), intraclass correlation coefficients are provided to indicate the interobserver reliability. 72 Journal of Manipulative and Physiological Therapeutics Nijs et al January 2007 Scapular Positioning in Shoulder Pain the LSST data correlated strongly with radiographic com- parison (r N 0.90). 28 The measurement of scapula upward rotation is a clinical assessment procedure that uses 2 Plurimeter-V gravity references inclinometers. 32 The patient is assessed in a relaxed, balanced standing position. The relative contribu- tion of the glenohumeral joint and the scapula to total shoulder abduction within the coronal plane is assessed. One inclinometer is Velcro-taped perpendicular to the humeral shaft, just above the humeral epicondyle. The resting position of the humerus is recorded. Next, the patient is instructed to perform shoulder abduction with full elbow extension, neutral wrist flexion/extension, and with the thumb leading to ensure vertical alignment of the inclinometer. The patient is asked to stop at 458, 908, 1358, and at their maximum achievable range. At each of the abduction positions, the scapula upward rotation is meas- ured with a second inclinometer, manually aligned along the scapular spine, and the patient is asked if any pain is present. Twenty-six patients with a variety of shoulder pathology were tested twice during a single testing session by a single tester. The overall intrarater reliability was very good (ICC = 0.88) and ranged from 0.81 to 0.94 across different testing positions. 32 A similar test using a Pro 360 digital protractor inclinometer, modified using 2 wooden locator rods, has been described previously for the clinical assessment of scapula upward rotation in patients with shoulder pain. 33 The 2-dimensional measurements of scapula upward rotation showed good to excellent intrarater reliability (ICCs varied from 0.89 to 0.96) and good validity in comparison with a magnetic tracking device (r varied from 0.59 to 0.92). 33 Given the fact that the muscular system is the major contributor to scapular positioning, it should be noted that clinicians should not assess scapular positioning without assessing scapular muscle function by use of specific, reliable, and valid manual muscle testing. This issue is beyond the scope of the present review, and the readers are consequently referred to the available scientific literature, such as the article by Michener et al. 34 DISCUSSION There is evidence suggesting that scapular positioning is abnormal in patients with shoulder impingement syndrome, 2 symptoms of impingement, 10,11 atraumatic shoulder insta- bility, 12 multidirectional shoulder joint instability, 13 and shoulder pain after neck dissection in cancer patients. 14,15 As no longitudinal study has yet been reported, it is not known if abnormal scapular positioning is a cause or consequence of shoulder pain or a secondary phenomenon caused by shoulder pain. In addition to the evidence from case-control studies, physiotherapy targeting the scapulo- thoracic muscles was found effective in patients with subacromial impingement syndrome, 16 and conservative treatments consisting of stretching and strengthening exer- cises targeting scapulothoracic muscles were able to improve scapular positioning in asymptomatic subjects. 35,36 Although it seems plausible, there is currently no evidence to show that assessing scapular positioning helps with the diagnosis or treatment of patients with shoulder pain. Future studies should address this issue. Clinicians are able to incorporate the available research data in their daily practice by interpreting the observation of static and dynamic scapular positioning pattern, including scapular rhythm, in relation to the relevant research data. From the literature overview presented here, it can be concluded that clinicians can use reliable tests for the assessment of both static and dynamic scapular positioning in patients with shoulder disorders. For the measurement of static scapular positioning, the measurement of the distance between the posterior border of the acromion and the table, the measurement of the distance from the medial scapular border to the third thoracic spinous process, and the assess- ment of the dscapular distanceT have been identified as reliable tests. In addition, the measurement of the distance fromthe medial scapular border to the fourth thoracic spinous process, when performed with the patients shoulders in active shoulder retraction, has been shown to have sufficient interobserver reliability. Apart from the study supporting the criterion validity of the assessment of the distance from the medial scapular border to the third thoracic spinous process, 26 the authors of the present article are unaware of studies addressing the validity of clinical tests for the assessment of static scapular positioning in patients with shoulder disorders. A clinical test should be both reliable and valid. If a test is not valid, then it is useless, regardless of whether it is reliable. For the measurement of dynamic scapular positioning, studies examining the reliability of the LSST were inconclusive, but the test was shown to have criterion validity. The measure- ment of scapula upward rotation was found reliable (intra- rater) and valid. The clinical relevance of the tests has yet to be shown. Further study of the clinimetric properties of the tests is warranted, especially for establishing normative data, for examining validity, responsiveness to change, and clinical importance. Indeed, normative data are essential to enable clinicians to interpret outcomes of tests for an individual patient. Studies examining the validity of a combination of tests, rather than a single test, for shoulder dysfunction or pathology are warranted. For studying the clinical impor- tance of the tests, cross-sectional (examining the associa- tions between the tests and symptom severity or disability), comparative (examining differences in scapular positioning between patients with shoulder pain and asymptomatic subjects), and prospective studies (examining whether the tests outcome is of prognostic value for patients with shoulder pain) are warranted. It should be noted that assessment of scapular positioning should be used in conjunction with objective measurements Nijs et al Journal of Manipulative and Physiological Therapeutics Scapular Positioning in Shoulder Pain Volume 30, Number 1 73 of scapular muscle performance. Indeed, the muscular system is the major contributor to scapular positioning, implicating that altered activity (delayed firing, decreased strength, or increased tension and consequent shortening) of scapular muscles prohibits normal scapular positioning. This was evidenced by a study showing decreased serratus anterior muscle activity in patients with shoulder impinge- ment syndrome relative to controls. 10 Delayed timing and inefficient recruitment are important because it may prohibit generating enough tension to enhance normal scapular positioning. Evaluation of scapular muscle (eg, serratus anterior, lower trapezius) performance with a handheld dynamometer has been found reliable. 34 CONCLUSION Scientific evidence supporting a role for faulty scapular positioning in patients with various shoulder disorders are accumulating. From a clinical point of view, it seems essential to have the skills to assess static and dynamic scapular positioning. Based on biometric and kinematic studies, an overview of the observation of static and dynamic scapular positioning pattern in patients with shoulder pain was provided. At this point, clinicians can use reliable clinical tests for the assessment of both static and dynamic scapular positioning in patients with shoulder pain, and some data supportive of the validity of the tests have been provided. ACKNOWLEDGMENT Nathalie Roussel and Filip Struyf are financially sup- ported by a research grant (bA study examining static and dynamic preventive factors for injuries in dancersQ) from the Department of Health Sciences, University College Ant- werp, Belgium. Filip Struyf is financially supported by a PhD grant (G826) from the Department of Health Sciences, University College Antwerp, Belgium. REFERENCES 1. Mottram SL. Dynamic stability of the scapula. Man Ther 1997; 2:123-31. 2. Hebert LJ, Moffet H, McFadyen BJ, Dionne CE. Scapular behavior in shoulder impingement syndrome. Arch Phys Med Rehabil 2002;83:60-9. 3. de Groot J. The scapulo-humeral rhythm: effects of 2-D roentgen projection. Clin Biomech 1999;14:63-8. 4. Sugamoto K, Harada T, Machida A, Inui H, Miyamoto T, Takeuchi E, et al. Scapulohumeral rhythm: relationship between motion velocity and rhythm. Clin Orthop Relat Res 2002;401:119-24. 5. Borsa PA, Timmons MK, Sauers EL. Scapular positioning patterns during humeral elevation in unimpaired shoulders. J Athl Train 2003;38:12-7. 6. Host HH. Scapular taping in the treatment of anterior shoulder impingement. Phys Ther 1995;75:803-12. 7. Schmitt L, Snyder-Mackler L. Role of scapular stabilizers in etiology and treatment of impingement syndrome. J Orthop Sports Phys Ther 1999;29:31-8. 8. Lewis JS, Green AS, Dekel S. The aetiology of subacromial impingement syndrome. Physiotherapy 2001;87:458-69. 9. Ackermann B, Adams R, Marshall E. The effect of scapula taping on electromyographic activity and musical performance in professional violinists. Aust J Physiother 2002; 48:197-204. 10. Ludewig PM, Cook TM. Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement. Phys Ther 2000;80:276-91. 11. Cools AM, Witvrouw EE, Declercq GA, Danneels LA, Cambier DC. Scapular muscle recruitment patterns: trapezius muscle latency with and without impingement symptoms. Am J Sports Med 2003;31:542-9. 12. von Eisenhart-Rothe R, Matsen FA, Eckstein F, Vogl T, Graichen H. Pathomechanics in atraumatic shoulder instability: scapula positioning correlates with humeral head centering. Clin Orthop Rel Res 2005;433:82-9. 13. Illyes A, Kiss RM. Kinematic and muscle activity character- istics of multidirectional shoulder joint instability during elevation. Knee Surg Sports Traumatol Arthrosc 2006;14: 673-85. 14. van Wilgen CP, Dijkstra PU, van der Laan BFAM, Plukker JTh, Roodenburg JLN. Shoulder complaints after neck dissection; is the spinal accessory nerve involved? Br J Oral Maxillofac Surg 2003;41:7-11. 15. van Wilgen CP. Morbidity after neck dissection in head and neck cancer patients. A study describing shoulder and neck complaints, and quality of life. Doctoral dissertation. Rijksu- niversiteit Groningen; 2004. p. 10-1. 16. Dickens VA, Williams JL, Bhamra MS. Role of physiotherapy in the treatment of subacromial impingement syndrome: a prospective study. Physiother 2005;91:159-64. 17. Sobush DC, Simoneau GG, Dietz KE, Levene JA, Grossman RE, Smith WB. The Lennie test for measuring scapula position in healthy young adult females: a reliability and validity study. J Orthop Sports Phys Ther 1996;23:39-50. 18. Lukasiewicz AC, McClure P, Michener L, et al. Comparison of 3-dimensional scapular position and orientation between subjects with and without shoulder impingement. J Orthop Sports Phys Ther 1999;29:574-83. 19. Borstad JD. Resting position variables at the shoulder: evidence to support a posture-impairment association. Phys Ther 2006;86:549-57. 20. Finley MA, Lee RY. Effect of sitting posture on 3-dimensional scapular kinematics measured by skin-mounted elec- tromagnetic tracking sensors. Arch Phys Med Rehabil 2003; 84:563-8. Practical Applications ! Evidence supporting abnormal scapular positioning in shoulder impingement syndrome and shoulder instability are cumulating. ! Clinicians should interpret the observation of static and dynamic scapular positioning patterns in relation to the relevant research data. ! Clinicians can use reliable tests for the assessment of both static and dynamic scapular positioning in patients with shoulder disorders. 74 Journal of Manipulative and Physiological Therapeutics Nijs et al January 2007 Scapular Positioning in Shoulder Pain 21. Lewis JS, Green A, Wright C. Subacromial impingement syndrome: the role of posture and muscle imbalance. J Shoulder Elbow Surg 2005;14:385-92. 22. Greenfield B, Catlin PA, Coats PA, Green E, McDonald JJ, North C. Posture in patients with shoulder overuse injuries and healthy individuals. J Orthop Sports Phys Ther 1995;21: 287-95. 23. Gibson MH, Goebel GV, Jordan TM, Kegerries S, Worrell TW. A reliability study of measurement techniques to determine static scapular position. J Orthop Sports Phys Ther 1995;21:100-6. 24. Nijs J, Roussel N, Vermeulen K, Souvereyns G. Scapular positioning in patients with shoulder pain: a study examining the reliability and clinical importance of 3 clinical tests. Arch Phys Med Rehabil 2005;86:1349-55. 25. Lewis J, Green A, Reichard Z, Wright C. Scapular position: the validity of skin surface palpation. Man Ther 2002;7:26-30. 26. Peterson DE, Blankenship KR, Robb JB, Walker MJ, Bryan JM, Stetts DM, et al. Investigation of the validity and reliability of four objective techniques for measuring forward shoulder posture. J Orthop Sports Phys Ther 1997;25:34-42. 27. DiVeta J, Walker ML, Skibinski B. Relationship between performance of selected scapular muscles and scapular abduction in standing subjects. Phys Ther 1990;70:470-6. 28. Kibler WB. The role of the scapula in athletic shoulder function. Am J Sports Med 1998;22:325-37. 29. Odom CJ, Taylor AB, Hurd CE, Denegar CR. Measurement of scapular asymmetry and assessment of shoulder dysfunction using the lateral scapular slide test: a reliability and validity study. Phys Ther 2001;81:799-809. 30. Koslow PA, Prosser LA, Strony GA, Suchecki SL, Mattingly GE. Specificity of the lateral scapular slide test in asympto- matic competitive athletes. J Orthop Sports Phys Ther 2003;33: 331-6. 31. McKenna L, Cunningham J, Straker L. Inter-tester reliability of scapular position in junior elite swimmers. Phys Ther Sports 2004;5:146-55. 32. Watson L, Balster SM, Finch C, Dalziel R. Measurement of scapula upward rotation: a reliable clinical procedure. Br J Sports Med 2005;39:599-603. 33. Johnson MP, McClure PW, Karduna AR. New method to assess scapular upward rotation in subjects with shoulder pathology. J Orthop Sports Phys Ther 2001;31:81-9. 34. Michener LA, Boardman ND, Pidcoe PE, Frith AM. Scapular muscle tests in subjects with shoulder pain and functional loss: reliability and construct validity. Phys Ther 2005;85: 1128-38. 35. Roddey TS, Olson SL, Grant SE. The effect of pectoralis muscle stretching on the resting position of the scapula in persons with varying degrees of forward head/rounded shoulder posture. J Man Manipulative Ther 2002;10:124-8. 36. Wang C-H, McClure P, Pratt NE, Nobilini R. Stretch- ing and strengthening exercises: their effect on three-dimen- sional scapular kinematics. Arch Phys Med Rehabil 1999;80: 923-9. Nijs et al Journal of Manipulative and Physiological Therapeutics Scapular Positioning in Shoulder Pain Volume 30, Number 1 75