1. Manual Therapy 16 (2011) 155e160
Contents lists available at ScienceDirect
Manual Therapy
journal homepage: www.elsevier.com/math
Original article
Scapular positioning and motor control in children and adults: A laboratory study
using clinical measuresq,qq
Filip Struyf a, b, Jo Nijs a, b, *, Stijn Horsten a, Sarah Mottram c, Steven Truijen a, Romain Meeusen b
a
Division of Musculoskeletal Physiotherapy, Department of Health Sciences, Artesis University College Antwerp, Antwerp, Belgium
b
Department of Human Physiology, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
c
Kinetic Control, UK
a r t i c l e i n f o a b s t r a c t
Article history: Introduction: The scapular muscular system is the major determinant of scapular positioning. In addition,
Received 14 May 2009 strength and muscular endurance develops from childhood through adolescence. It is not known
Received in revised form whether differences in scapular positioning and motor control between adults and children may exist.
9 August 2010
Methods: Ninety-two shoulders of 46 adults (mean ¼ 39.4; 18e86 years; SD ¼ 22.5), and 116 shoulders of
Accepted 14 September 2010
59 children (mean ¼ 11.6; 6e17 years; SD ¼ 3.5), were included in the study. Scapular positioning data
were collected using a clinical assessment protocol including visual observation of titling and winging,
Keywords:
measurement of forward shoulder posture, measurement of scapular upward rotation, and the Kinetic
Scapula
Shoulder
Medial Rotation Test (KMRT).
Assessment Results: The observation protocol for scapular winging and tilting did not show significant differences
between adults and children. After controlling for height, forward shoulder posture (relaxed (0.28 cm/cm
(0.06) vs. 0.31 cm/cm (0.07) and retracted (0.15 cm/cm (0.05) vs. 0.20 cm/cm (0.06)) were significantly
smaller in children than in adults (P < 0.01). In addition, children showed greater scapular upward
rotation (18.6 ; SD 9.6 ) than adults (14.5 ; SD 10.9 ) at 90 shoulder abduction. No significant differences
were seen between children (19% positive test) and adults (24% positive test) using the KMRT.
Conclusion: Children and adults show significant but small differences in scapular upward rotation and
forward shoulder posture. These data provide useful reference values using a clinical protocol.
Ó 2010 Elsevier Ltd. All rights reserved.
1. Introduction indicators of known reliability and validity that allow clinicians to
assess static and dynamic scapular positioning and motor control.
Abnormalities of scapular positioning have been shown in These measurements are available, but should generate reliable and
patients with shoulder impingement syndrome, anterior shoulder valid data, and should have strong clinical utility (Sugamoto et al.,
instability, and postoperative shoulder complaints (Paletta et al., 2002; Nijs et al., 2007).
1997; Lukasiewicz et al., 1999; Ludewig and Cook, 2000; Hébert Decreased scapular upward rotation, reduced posterior tilting,
et al., 2002; Wilgen van et al., 2003). The complex kinematic and excessive scapular internal rotation have been identified as
behaviour of the scapula and shoulder has typically been studied altered scapular positioning patterns in patients with shoulder
(McKenna et al., 2004), using three-dimensional motion tracking disorders (Lukasiewicz et al., 1999; Ludewig and Cook, 2000; Hébert
systems. However, these are costly and not readily available for et al., 2002). It has been shown that people with short pectoralis
clinical practice (Sugamoto et al., 2002). There is a need for clinical minor muscle length demonstrate similar scapular positioning as
patients with shoulder impingement syndrome (Lukasiewicz et al.,
1999; Ludewig and Cook, 2000; Borstad and Ludewig, 2005; Smith
q We certify that no party having a direct interest in the results of the research
et al., 2006). This observation supports the use of a pectoralis
supporting this article has or will confer a benefit on us or on any organization with
which we are associated AND, if applicable, we certify that all financial and material
minor muscle length test for analyzing scapular positioning.
support for this research (e.g., NIH or NHS grants) and work are clearly identified in In addition, a lack of scapulothoracic muscle control has been
the title page of the manuscript. identified as a characteristic of people with shoulder disorders (Host,
qq The study protocol was reviewed and approved by the medical ethics
1995; Schmitt and Snyder-Mackler, 1999; Hess, 2000; Ackerman
committee of the University Hospital Brussels (2006/138).
et al., 2002; Cools et al., 2003; Nijs et al., 2007). When assessing
* Corresponding author. Campus HIKE, Dept G, Artesis Hogeschool Antwerpen,
Van Aertselaerstraat 31, 2170 Merksem, Belgium. Tel.: þ3236418265. scapular positioning or motor control, clinicians must be attentive
E-mail address: jo.nijs@artesis.be (J. Nijs). for patterns that are often seen in patients with shoulder disorders.
1356-689X/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.math.2010.09.002

2. 156 F. Struyf et al. / Manual Therapy 16 (2011) 155e160
Movement skills in children may be influenced by strength and
muscular endurance. Hence, movement patterns develop from
childhood through adolescence (Branta et al., 1984). Since the
scapular muscular system is the major contributor to scapular
positioning, differences in scapular positioning and motor control
between adults and children may exist (Nijs et al., 2005; Dayanidhi
et al., 2005). In fact, significant differences in scapular kinematic
patterns between children (4e9 years) and adults (25e37 years)
have previously been reported (Dayanidhi et al., 2005). The authors
reported that children have a greater contribution of the scap-
ulothoracic joint to upper limb movements (Karduna et al., 2001). A
previous study using radiographic evaluation identified a decrease
in the range of the posterior tilt and upward rotation as an ageing
effect (Endo et al., 2004). Numerous studies have investigated the
applicability of clinical tests for assessing scapular positioning in
adults. Given the fact that differences in scapular positioning
between children and adults are present, the use of these clinical
tests to assess children requires additional study. Fig. 1. Winging of the right scapula.
The primary aim of the study was to provide clinicians with data
for interpreting clinical tests when assessing scapular positioning
and motor control in adults and children. The secondary aim of this Prior to the study, the assessor (holder of a bachelor degree in
study was to examine whether clinical measures revealed differ- physiotherapy) underwent a 4-h training session. The training
ences in scapular positioning (i.e. scapular upward rotation, tilting, session was used to instruct the assessor in performing an accurate
winging, forward shoulder posture, and scapular motor control) measurement of scapular positioning and scapular dynamic control
between adults and children. including pilot testing on healthy subjects. The assessor was trained
by two instructors, one manual therapist, with 10 years of clinical
experience, and one sports physical therapist with 5 years of clin-
2. Methods
ical experience. Both assessor and instructors performed test
evaluations without knowledge of each other’s outcome. When all
2.1. Subjects
three (both assessor and instructors) finished the evaluation,
results were compared and discussed.
Both shoulders of 105 subjects were measured yielding data for
a total of 210 shoulders for further analysis. Children (n ¼ 59; mean
age 11.6; 6e17 years; 30 ; 83% right handed) were recruited from 2.3. Outcome measures
local schools. The adult group (n ¼ 46; mean age 39.4; 18e86 years;
17 ; 93% right handed) comprised of a sample of convenience. To 2.3.1. Visual observation for tilting and winging
be included in the trial, subjects had to be at least 6 years of age. The The observation was performed with the subject instructed to
exclusion criteria for all subjects were shoulder pain, neck pain and stand relaxed (barefoot). The subject was observed from dorsal
a history of injury or surgery to the shoulder complex, upper (frontal plane) and lateral (sagittal plane). Ideally, the inferior angle
thorax, upper back or humerus during the previous year. The should be flat against the chest wall (Mottram, 1997) and the
exclusion criteria for all subjects were shoulder pain, neck pain and scapula should be 30 internally rotated with respect to the frontal
a history of injury (in the previous year) or surgery (life-time) to the plane (De Groot, 1999). Scapular positioning was deemed impaired
shoulder complex, upper thorax, upper back or humerus. when: (1) the inferior angle of the scapula became prominent
Prior to clinical assessment, all participants received an infor- dorsally (rotating about the horizontal axis e tilting); (2) the entire
mation leaflet and provided written informed consent. Minors medial border of the scapula became prominent dorsally (rotation
provided their verbal agreement and a written informed consent about the vertical axis e winging: Fig. 1). If one (or more) of the
from their parents or responsible adult. The study protocol was criteria listed above were fulfilled, then we judged scapular posi-
reviewed and approved by the medical ethics committee of the tioning as impaired (score ¼ 1). If none of the criteria were met,
University Hospital Brussels (2006/138). The male subjects and all then scapular positioning was judged normal. Next, in standing the
children (12 years) were tested with their trunk bare. Female subject performed active maximal range of abduction. No differ-
subjects wore a sports bra or a halter-top so that the scapula entiation in the amount of abduction was specified. The same
remained visible and shoulder movements were not hampered by criteria as above were used to check for winging and tilting.
clothing. All reference points that were used during the inclinom- Systematically, both upward and downward upper limb move-
etry and acromion-table distance were palpated (Lewis et al., 2002; ments had to last 5 s each. Scapular positioning was only deemed
Morrissey et al., 2008). abnormal if there was a clear observation of the positioning fault.
Each position was observed and evaluated once.
2.2. Study design
2.3.2. Forward shoulder posture (acromial distance)
After measuring the subjects body mass and height, clinical The Acromial Distance was defined as the measurement of the
assessment was performed in the following order: observation of posterior border of the acromion to the table in supine (measured
forward tilt and winging, measurement of forward shoulder vertically with a sliding calliper e ManutanÔ, accuracy 0.03 mm)1,
posture (the acromial distance), scapular upward rotation (inclin- intended to represent forward shoulder posture. The assessor
ometry) and scapular dynamic control Kinetic Medial Rotation Test repeated this procedure while the subject actively retracted both
(KMRT)). After the assessment protocol, height and body mass were
measured using a measurement tape and a digital scale (Exacta,
1
Germany). Manutan nv, 19 Doverstraat, Brussels, 1070, Belgium.

3. F. Struyf et al. / Manual Therapy 16 (2011) 155e160 157
shoulders. The subject was instructed to keep the thorax still in
relation to the examination table. The data collected with this
measurement were adjusted by dividing the measured distance by
the body length (BL), which resulted in a score entered as cm/cm.
Each position was measured once.
2.3.3. Scapular upward rotation (inclinometry)
A gravity referenced inclinometer (Plurimeter-V, Dr. Rippstein,
Switzerland; accuracy to 1 )2 (Green et al., 1999) was used to
measure shoulder elevation, and a second inclinometer was used to
measure upward rotation of the scapula. Again, all subjects were
assessed in a relaxed, standing (barefoot) position. Subjects were
asked to perform full extension at the elbow, neutral wrist position,
and with the thumb leading in the coronal plane. The inclinometer
was attached perpendicular to the humerus, just under the deltoid
insertion, with use of a Velcro tape. Subjects were then asked to
actively move both arms into abduction and to hold at 45 , 90 and
135 of humeral abduction (measured with an inclinometer)
(Fig. 2). The resting position of shoulder abduction was taken as
zero. The degree of upward rotation of the scapula was measured Fig. 2. Measurement of scapular upward rotation at 90 humeral abduction by means
using the second inclinometer. This was achieved by manually of 2 inclinometers.
aligning the base of the inclinometer along the spine of the scapula.
Acromial Distance was found to generate reliable data (ICC 0.88)
Each subject underwent one test-rehearsal before the test was
(Nijs et al., 2005) and is suggested to be indicative for pectoralis
performed. The scapulohumeral rhythm was calculated by dividing
minor muscle length (Host, 1995). Likewise, the plurimeter-V can
the shoulder elevation (humerothoracic) by the scapular upward
be used in an effective and reliable manner for the measurement of
rotation (scapulothoracic).
scapular upward rotation during shoulder elevation in the coronal
plane (ICC ¼ 0.88) (Green et al., 1999; Watson et al., 2005). In
2.3.4. Kinetic medial rotation test
addition, excellent intrarater reliability was found for the assess-
The KMRT was used to indicate movement faults at the scapula
ment of scapular upward rotation in four static positions of
and glenohumeral joint associated with glenohumeral medial
humeral elevation (Johnson et al., 2001). Validity has been shown
rotation (Comerford and Mottram, 2001, 2003; Morrissey et al.,
when comparing an inclinometer to a three-dimensional motion-
2008). The test has been developed based on the combination of
tracking device (Johnson et al., 2001). Finally, the KMRT has been
clinical experience and research results addressing shoulder girdle
validated against dynamic ultrasound (Morrissey, 2005).
movement (Mottram, 1997, 2003; Comerford and Mottram, 2001;
Morrissey et al., 2008). The subject was positioned supine with
2.3.5.1. Data analysis. Means, standard deviations, and ranges were
the humerus abducted to 90 in the scapular plane (hand to the
calculated for all measured and corrected (AT-distance) data. A 1-
ceiling with the humerus in the plane of the scapula). The subject
sample KolmogoroveSmirnov goodness-of-fit test was used to
was taught to perform medial rotation at the glenohumeral joint at
identify normal distribution. Since the descriptive data revealed
90 abduction whilst keeping the scapula still in its neutral posi-
some high ranges, box plots were used to detect possible outliers.
tion. The assessor then palpated the humeral head and coracoid
For within subgroup comparisons, a Bonferroni adjustment for the
processes for translation (Fig. 3). The KMRT was performed up to
correction of Type 1 errors was performed. No significant differ-
60 of medial rotation. Normative research data suggested that
ences were found between the left and the right shoulder, therefore
during medial rotation to 60 e in non-painful shoulders e the
both left and right shoulder were analysed together. An indepen-
glenoid did not translate anteriorly more than 4 mm, and the
dent-samples T-test was used when analysing the difference
scapula did not translate more than 6 mm (Morrissey et al., 2008).
between adults and children using the inclinometry and acromial
For this experiment test scoring was twofold: first, this test was
scored positive (score ¼ 1) when the assessor felt that the scapula
tilted forward or when elevation occurred. Second, the test was
scored positive when the subject showed difficulties in performing
the test (alteration of breathing pattern, feedback needed, support
needed, effort needed) (Comerford and Mottram, 2001). Each
subject underwent one test-rehearsal before the test was
performed.
2.3.5. Reliability and validity
Previous study on the inter-tester reliability of scapular obser-
vation concluded that observation of the scapula is a reliable tool
for screening prominence of the medial scapular border (winging)
and prominence of the inferior scapular angle (tilting) during
unloaded movement in healthy musicians (Kappa of 0.48 and 0.42
at rest, and 0.52 and 0.78 during unloaded movement respectively
for tilting and winging) (Struyf et al., 2009). In addition, the
2
Plurimeter-V, Dr. Rippstein, 1093 La Conversion, Switzerland. Fig. 3. Kinetic Medial Rotation Test.

4. 158 F. Struyf et al. / Manual Therapy 16 (2011) 155e160
Table 1
Differences between adults and children in different scapular parameters.
Test Observed position or movement fault Children (n ¼ 116) Adults (n ¼ 92) P-value Power
(SD) (SD)
Observation Tilting present 17 (15%) 18 (20%) 0.51
Winging present 14 (12%) 16 (17%) 0.41
AT-distance Relaxed position (cm/cm) 0.28 (0.06) 0.31 (0.07) 0.00 0.86
Retracted position (cm/cm) 0.15 (0.05) 0.20 (0.06) 0.00 0.99
Inclinometry Scapular upward rotation at rest ( ) À12.4 (6.2) À11.8 (6.2) 0.12 0.21
Scapular upward rotation at 45 humeral elevation ( ) À4.8 (8.4) À5.7 (10.3) 0.47 0.57
Scapular upward rotation at 90 humeral elevation ( ) 18.6 (9.6) 14.5 (10.9) 0.01 0.60
Scapular upward rotation at 135 humeral elevation ( ) 49.9 (14.3) 47.3 (19.8) 0.32 0.54
Ratio from 0 to 45 of humeral abduction 7.1 (12.6) 6.6 (13.9) 0.81 0.53
SH ratio from 45 to 90 of humeral abduction 2.4 (1.5) 3.2 (3.2) 0.04 0.82
SH ratio from 90 to 135 humeral abduction 1.6 (0.7) 1.6 (2.2) 0.86 0.63
KMRT Negative KMRT 107 78 0.14
Positive KMRT 11 14 0.14
Abbreviations: SD: standard deviation; SH: scapulohumeral. Bold values: P 0.05.
distance. The ManneWhitney U test was used to identify potential study identified a number of statistically significant differences in
differences for the KMRT. A post-hoc power analysis was performed scapular positioning between children and adults.
for identification of possible type-II errors. A power of 80% was set First, the observation protocol for scapular winging and tilting
as standard for adequacy. The power analysis was performed using did not show significant differences between adults and children.
SigmaStat 3.1 (Systat Software, Inc., San Jose, CA). Except for the We suggest to further explore the observation of downward scap-
power analysis, data were analysed using SPSS version 12.0, for ular rotation as this was previously identified as variable with
Windows (SPSS, Chicago, Illinois, US)3. increasing age (Endo et al., 2004). These results should be taken
into account when assessing scapular positioning in subjects
without shoulder disorders: not all cases of scapular winging or
3. Results scapular tilting are related to shoulder impairments.
Second, forward shoulder posture was significantly smaller in
Table 1 shows all differences between adults and children (Table children than in adults. After controlling for the BL, the mean AT-
1). Overall, 15% of the study population demonstrated tilting, while distance of children in relaxed and with bilateral shoulder retrac-
11% showed winging. The observation protocol for scapular wing- tion was smaller than in adults. Since the AT-distance is closely
ing and tilting did not show significant differences between adults related to the pectoralis minor muscle length and posterior tilting,
and children. The BL correlated with the distance of the posterior this finding is consistent with an earlier report of increased
border of the acromion and the table (r 0.46 relaxed; P 0.01 and posterior tilt in children compared to adults (Dayanidhi et al.,
r 0.40; P 0.01 retracted). The distance between the acromion 2005). Additional comparison to other study results is not
and the table with both shoulders relaxed was significantly smaller possible: this is the first study to report body length-corrected data
in children than in adults (P 0.01). Fig. 4 shows the scapular of the Acromial Distance. These indicative data may assist manual
upward rotation in the different age categories. First, an decreased therapists identifying abnormal forward shoulder posture.
scapular upward rotation is seen up to the 25e55-year-old group.
After that, the scapular upward rotation increased. Combining the
data of all subjects studied here, mean scapulohumeral ratio up to
135 of shoulder abduction was 2.76:1. Children showed greater
50
humeral elevation angles (158.9 ; SD 7.8 ) than adults (151.4 ; SD
9.8 ) (P 0.001). In addition, children demonstrated with signifi-
cantly smaller scapulohumeral ratios in comparison to adults 40
(P 0.05). A total of 11.9% (n ¼ 25) of all shoulders showed
Scapular upward rotation
a positive KMRT. No significant difference was noted between
children’s and adult’s shoulders. A total of 11 children (¼19%) 30
demonstrated with a positive KMRT, whereas 14 adults showed
positive results (¼24%). With the sample of 116 children and 92
adults, power is greater than 0.8 for the AT-distance. Using the 20
Inclinometry, only the SH ratio from 45 to 90 of humeral
abduction attained sufficient power.
10
4. Discussion
0
Shoulder abduction involves a complex variety of movements
that has been the subject of numerous studies and discussions. The
present study has attempted to provide clinicians with indicative -10
data for interpreting clinical tests when assessing scapular posi-
tioning and motor control in adults and children. Secondly, this 6-11 years 12-17 years 18-23 years 24-56 years 56-86 years
category
3
SPSS Inc., 233 S Wacker Dr, 11th Fl, Chicago, IL 60606, US. Fig. 4. Scapular upward rotation between the five age categories.

5. F. Struyf et al. / Manual Therapy 16 (2011) 155e160 159
Third, when comparing scapular upward rotation between static measurements during various positions of arm elevation were
children and adults by means of two inclinometers, significant used to describe the scapulohumeral rhythm, which may not suffi-
differences were found between the two age groups. Dayanidhi et al. ciently represent functional movement patterns. Third, the number
(2005), previously showed that children display more scapular of study participants who had experienced a shoulder injury more
upward rotation (43.9 ; SD 6.4) than adults (29.1 ; SD 10.1). than 1 year prior to study participation, was not registered. Fourth,
However, they studied scapular upward rotation from 25 to 125 of although concurrent validity of the digital inclinometers is known to
humeral elevation, while the present study examined up to 135 of be excellent (Johnson et al., 2001), this has not yet been reported for
humeral abduction This explains their lower degrees of upward the analogue inclinometers. Finally, although previous studies on
rotation in contrast to the present study. Watson et al. (2005) used the inter-tester reliability of clinical assessment tools (Green et al.,
the same measurements to study 26 adult shoulder patients. Overall, 1999; Johnson et al., 2001; Nijs et al., 2005; Watson et al., 2005;
their patients demonstrated larger degrees of scapular upward Struyf et al., 2009) concluded that they are reliable for screening
rotation at rest (3.75 ), 45 (13 ) and 90 (28.3 ) of humeral scapular positioning, no inter-tester reliability analysis was per-
abduction than our adult study subjects (rest: À11.8 ; 45 :À5.7 and formed to test the assessor’s accuracy. In addition, all our methods of
90 :14.5 ). However, above 90 of humeral elevation, the adults in measuring and scoring of scapular motion should be validated
the present study demonstrate more scapular upward rotation against accurate motion analysis. It is clear from the methodological
(135 :47.3 ) than the patients in Watsons’ study (135 :43.2 ). The problems encountered here that, because of the complexity of
scapulohumeral rhythm is described as the relative movement assessing three-dimensional motions, it is necessary to train manual
between the scapula and the humerus during arm movements. The therapists in the difficulties and pitfalls in interpreting scapular
scapulohumeral rhythm is therefore defined as the ratio of the gle- kinematics (Baeyens et al., 2005).
nohumeral movement to the scapulothoracic movement during arm The post-hoc power analysis demonstrated sufficient power for
elevation. In addition, several studies demonstrated similar scap- the measurement of AT-distance, and the SH ratio from 45 to 90 of
ulohumeral ratios ranging from 1.7:1 (McQuade and Smidt, 1998), humeral abduction. The lack of power in the other measurements
2.1:1 (Graichen et al., 2001), 2.4:1 (Sugamoto et al., 2002), up to 2.6:1 can be due to the magnitude of the study sample. However, we
(De Groot,1999). The wide range of reported ratios appears to be due believe a more precise measurement protocol would result in
to differences in measurement techniques and methodologies for smaller standard deviations and subsequently increase the power.
describing and defining scapulohumeral rhythm (McQuade and In conclusion, our findings suggest that the clinical assessment
Smidt, 1998). As a disrupted balance between scapular upward protocol, and more specific the measurement of scapular upward
rotation and humeral elevation might increase the risk of developing rotation and forward shoulder posture, has identified a significant
shoulder disorders, assessment of scapular upward rotation and the difference between children and adults: therapists can use these
scapulohumeral rhythm are essential for physical therapists clinical tools in both children and adults. In addition, manual
(Sugamoto et al., 2002). therapists can use the data presented here to identify abnormal
When searching scientific literature for differences between scapular positioning: scapular upward/downward rotation or
children and adults, the study by Dayanidhi et al. (2005) reported forward/backward shoulder posture (measured with analogue
the following glenohumeral to scapulothoracic ratios between 25 inclinometers or the AT-distance) that exceed the presented values
and 125 of humeral elevation: 2.4:1 for adults and 1.3:1 for chil- (taking the SD into account), should alert therapists for a possible
dren. This is inline with our findings. However, they did not include scapular position that increases the risk for shoulder pathologies.
subjects older than 46 years of age. In addition, between 45 and However, future work should aim at searching for a cut-off value for
90 of shoulder abduction, children demonstrated significantly identifying abnormal scapular postures associated with increased
smaller scapulohumeral ratios than adults. During this phase of risk for shoulder pathology.
humeral abduction, a mechanical compression of the rotator cuff is
possible, creating a condition that is related with the subacromial Acknowledgments
impingement syndrome (McClure et al., 2006). Thus, adults
demonstrate lesser scapular upward rotation during this phase, This study was financially supported by a research grant (G826)
which might explain the greater incidence numbers of shoulder supplied by the Department of Health Sciences, Artesis University
impingement syndrome in adults. However, direct measurement of College Antwerp, Antwerp, Belgium.
the subacromial space distance is required to confirm this. Finally,
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