Original Article

STATIC EVALUATION OF SCAPULAR POSITIONING IN

HEALTHY INDIVIDUALS

José Carlos Baldocchi Pontin1, Simone Pivaro Stadniky1, Paula Tiaki Suehara1, Thiago Ragusa Costa1, Therezinha Rosane Chamlian1

Abstract evaluator. Results: 73.3% of the subjects showed positioning

Objective: Evaluate the static positioning of the scapula on of the scapula considered normal. The inter-examiner reliability
and that of the clinical examination in relation to radiography
the rib cage in healthy subjects by means of clinical and
were considered low and very low, respectively. Conclusion:
radiographic evaluation to assess inter-examiner reliability of
The reproducibility of the evaluation performed by Burkhart
clinical examination and verify the reliability of this evaluation was considered satisfactory to good, while the inter-examiner
method compared to the radiographic examination. Methods: reproducibility of the clinical examination and the static
We selected 30 adult individuals of both sexes with no diagnosis reproducibility of the clinical examination with radiography were
of shoulder pathology. The static clinical examination, following considered poor to satisfactory. Level of Evidence III, Study
the protocol suggested by Burkhart et al, was performed of Nonconsecutive Patients.
repeatedly by two independent examiners, followed by the
radiographic examination, which was later examined by the first Keywords: Scapula. Evaluation. Radiography. Humans.

Citation: Pontin JCB, Stadniky SP, Suehara PT, Costa TR, Chamliam TR. Static evaluation of scapular positioning in healthy individuals. Acta Ortop Bras. [online]. 2013;21(4):208-
12. Available from URL: http://www.scielo.br/aob.

INTRODUCTION positioning are related to several conditions that involve the

The essential role of the scapula is to guarantee the appro- glenohumeral joint, such as the impingement syndrome, rotator
cuff injuries and instabilities. In this context, the evaluation of
priate functionality of the upper limb, serving as a base for
scapular positioning is an integral and essential part of the clini-
origin and insertion of many muscles of the shoulder complex,
cal practice of orthopedists, physiatrists and physiotherapists.6-8
besides containing the acromion and the glenoid, which serves
However, there is no consensus in the literature about the ap-
to couple the humeral head, affording stability and allowing
propriate positioning of the scapula on the rib cage with the
joint mobility.1,2
upper limbs at rest, which complicates the standardization of
Alterations in scapular positioning at rest and in movement, collected data, the comparison of published studies and the
called scapular dyskinesis, are associated with various diseases analysis of results of the proposed treatment.2,4,5,8
of the shoulder, such as the impingement syndrome, rotator cuff Accordingly, this study had the following objectives: to evaluate
tear, instabilities and adhesive capsulitis.3,4 the static positioning of the scapula on the rib cage of individuals
Some etiological factors contribute to this scenario, such as without shoulder injuries, to assess inter-examiner reliability of
anatomical reduction between the subacromial space, intrinsic static clinical examination of scapular positioning on the rib
degeneration of the tendon caused by eccentric overload, tissue cage and to verify the reproducibility of the evaluation method
ischemia, aging and alterations in the movement of the scapula compared to the radiographic examination.
and of the humerus, which leads to the impairment of the cuff
muscles due to pinch in the anterior inferior portion of the acro- METHODOLOGY
mion or in the posterior superior portion of the glenoid labrum.4,5 This study was authorized by the Institutional Review Board
Cases of scapular dyskinesis provoke alterations in the kine- of Universidade Federal de São Paulo/Hospital São Paulo in
matics of the glenohumeral and acromioclavicular joints and accordance with resolution CEP 0901/09.
interfere in the activity of the periscapular muscles and of the The study subjects were adult individuals (over 18 years of age,
rotator cuff, and can also generate pain and reduced functional skeletally mature), without a diagnosis of previous diseases
capacity of the upper limb. Moreover, alterations in scapular and/or injuries involving the bilateral shoulder joint.

All the authors declare that there is no potential conflict of interest referring to this article.

1. Department of Orthopedics and Traumatology of Universidade Federal de São Paulo – Escola Paulista de Medicina. São Paulo, SP, Brazil.

Work performed at Department of Orthopedics and Traumatology of Universidade Federal de São Paulo – Escola Paulista de Medicina. São Paulo, SP, Brazil.
Mailing address: Departamento de Ortopedia e Traumatologia – UNIFESP. Rua Napoleão de Barros, 715, 1º andar. 04024-002, São Paulo, SP. Brazil. [email protected]

Article received on 4/17/2012 and approved on 8/8/2012.

208 Acta Ortop Bras. 2013;21(4):208-12

Individuals presenting rheumatological diseases, previous le- quested and carried out on the same day and at the same place
sions in other joints of the upper limbs, alterations of the spinal as the physical examination, which consisted of standardized an-
column and cognitive deficit were excluded from the survey. teroposterior view radiography of the scapula for evaluation of the
All the individuals who agreed to take part in the study received static positioning of the scapula according to the measurement pa-
and signed the informed consent form, containing all the mate- rameters used in the clinical examination, carried out by examiner 1.
rial information relating to the procedures applied in this study.
The selected individuals were referred to the Shoulder and El- RESULTS
bow Outpatient Clinic of Hospital São Paulo, where the scapular The sample was formed by 30 healthy subjects, made up of 17
positioning was evaluated according to the protocol suggested (56.7%) women and 13 (43.3%) men, aged between 18 and 49
by Burkhart et al.9 years and averaging 24.5 years (sd=7.1 years). All the subjects
In the evaluation, the individual was positioned upright, with had the right side as dominant.
arms relaxed alongside the body and trunk naked. Two Tables 1 to 7 contain the descriptive measurements of the physical
examiners (examiner 1 and examiner 2), trained in and familiar examination and radiography evaluations.
with the proposed evaluation technique, were selected to carry The four individuals with vertical distance of the superior angle
out the evaluations. Examiner 1 marked points using stickers of the two scapulae > 1.5 cm are not the same four individuals
in the upper and lower angles, on the medial borders of both with the difference between right and left sides of the distance
scapulae and also on the spinous process of the vertebrae (T1 between the superior angle of the scapula and the midline of the
to T3) located between the scapulae with the use of a universal spinal column > 1.5 cm. Thus, eight (26.7%) of the individuals
goniometer, evaluating: (1) the difference in vertical distance, have one of the measurements altered.
in centimeters, from the superior angle of the two scapulae; The mean value of the differences in distances between the
(2) the difference between the distance from the superior angle superior angle of the scapula and the midline of the spinal
of the scapula and the line drawn over the spinous processes, column on the left side measured by examiners 1 and 2 was
bilaterally and (3) the difference in angular degrees of the medial significantly different from 0 (p = 0.035), indicating larger
border of the scapula and the vertical line (spine) of both scapulae, measurements taken by examiner 2..
measured with the use of a goniometer with the fulcrum positioned The mean values of the other differences were not significant in
at the inferior angle of the scapula, the fixed arm parallel to the comparison to 0 (p > 0.05 in all the comparisons).
spine and the mobile arm on the medial border of the scapula. The ICC values for the measurements of the angle between the
(Figure 1) Differences greater than 1.5 cm for measurements (1) medial border and the vertical line of the superior angle of the
and (2); and greater than 5 degrees for measurement (3), were scapula on the right and left sides represent poor reproducibility
considered abnormal. The same examination was then repeated of the measurements. The ICC values for the measurements of
by the second examiner, who did not have access to the results the vertical distance of the superior angle of the two scapulae
obtained by the first examiner, so as not to interfere in the reliability and of the distance between the superior angle of the scapula
of the examination. and the midline of the spinal column on the right and left sides
After the clinical evaluation, a radiographic examination was re- represent satisfactory reproducibility of the measurements.
The mean difference of the vertical distances of the superior angle
of the two scapulae measured by examiner 1 and radiography
was significantly different from 0 (p = 0.038) indicating larger
measurements taken by examiner 1.

Table 1. Vertical distance of the superior angle of the two scapulae (cm).
Measurements – n (%) (n = 30)
0.0 2 (6.7)
0.2 2 (6.7)
0.3 4 (13.3)
0.4 1 (3.3)
0.5 3 (10.0)
0.7 2 (6.7)
0.8 2 (6.7)
0.9 3 (10.0)
1.0 6 (20.0)
1.4 1 (3.3)
Figure 1. Measurements taken in the static evaluation of scapular positioning. 1)
1.8 1 (3.3)
Difference of the vertical distance in cm, of the superior angle of the two scapulae;
2) Difference between the distance of the superior angle of the scapula and the 1.9 2 (6.7)
line drawn over the spinous processes; 3) Difference in angular degrees of the
3.3 1 (3.3)
medial border of the scapula and the vertical line of both scapulae.
N.B.: Four (13.3%) individuals with altered measurements, i.e., distance > 1.5cm.

Acta Ortop Bras. 2013;21(4):208-12

209
 Table 2. Measurements of the scapular positioning. Table 5. Scapular positioning in health individuals.
Distance between the superior angle of the Difference between the right Evaluation
scapula and the midline of the spinal column and left sides Variables Physical Examina- Physical Examina-
Radiography
tion – Examiner 1 tion – Examiner 2
Measurements (cm) Measurements (cm)
Right side Left side (n = 30) Vertical distance of the
– n (%) (n = 30) – n (%)
superior angle of the two
6.0 0 (0.0) 1 (3.3) -1.0 1 (3.3) scapulae (cm)
6.5 0 (0.0) 2 (6.7) -0.8 1 (3.3) mean (sd) 0.85 (0.69) 0.75 (0.52) 0.59 (0.38)
7.0 1 (3.3) 1 (3.3) -0.7 1 (3.3) median 0.8 0.65 0.55
7.5 1 (3.3) 4 (13.3) -0.5 1 (3.3) minimum – maximum 0 – 3.3 0.2 – 2.8 0 – 1.4
8.0 3 (10.0) 4 (13.3) -0.2 1 (3.3) percentile 5% 0 0.20 0
8.2 2 (6.7) 0 (0.0) -0.1 2 (6.7) percentile 95% 2.53 2.14 1.34
8.3 1 (3.3) 1 (3.3) 0.0 2 (6.7) CI 95% [0.59; 1.11] [0.55; 0.94] [0.44; 0.73]
8.4 1 (3.3) 0 (0.0) 0.1 1 (3.3) Distance between the superior
8.5 2 (6.7) 4 (13.3) 0.2 3 (10.0) angle of the scapula and the
8.7 2 (6.7) 0 (0.0) 0.3 2 (6.7) midline of the spinal column –
R Side (cm)
8.8 2 (6.7) 0 (0.0) 0.5 2 (6.7)
9.0 0 (0.0) 6 (20.0) 0.7 1 (3.3) mean (sd) 9.1 (1.1) 9.3 (1.3) 9.2 (1.2)
9.2 2 (6.7) 0 (0.0) 1.0 5 (16.7) median 9.0 9.4 9.2
9.3 1 (3.3) 0 (0.0) 1.2 1 (3.3) minimum – maximum 7.0 – 12.0 7.2 – 12.6 6.8 – 11.5
9.5 5 (16.7) 2 (6.7) 1.5 2 (6.7) percentile 5% 7.3 7.2 7.1
9.6 0 (0.0) 1 (3.3) 2.0 2 (6.7) percentile 95% 11.7 12.0 11.4
CI 95% [8.7; 9.5] [8.8; 9.8] [8.8; 9.7]
9.7 2 (6.7) 0 (0.0) 2.3 1 (3.3)
Distance between the superior
10.0 1 (3.3) 2 (6.7) 3.0 1 (3.3)
angle of the scapula and the
10.5 1 (3.3) 1 (3.3) midline of the spinal column –
11.0 1 (3.3) 0 (0.0) L Side (cm)
11.5 1 (3.3) 0 (0.0) N.B.: Four (13.3%) individuals mean (sd) 8.5 (1.2) 8.9 (1.4) 9.0 (1.3)
11.7 0 (0.0) 1 (3.3) with altered measurements, i.e., median 8.5 9.0 9.2
12.0 1 (3.3) 0 (0.0) distance > 1.5cm minimum – maximum 6.0 – 11.7 6.0 – 12.0 6.3 – 11.5
percentile 5% 6.3 6.3 6.4
percentile 95% 11.0 11.6 11.1
Table 3. Angle between the medial border and the vertical line of the CI 95% [8.0; 9.0] [8.4; 9.4] [8.5; 9.5]
superior angle of the scapula (º).
Angle between the medial
Measurements – n (%) (n = 30) Right side Left side border and the vertical line
0.2 1 (3.3) 0 (0.0) of the superior angle of the
scapula – R Side (º)
0.4 0 (0.0) 1 (3.3)
mean (sd) 3.9 (1.8) 4.5 (1.8) 4.5 (2.7)
2.0 9 (30.0) 11 (36.7)
median 4.0 4.0 4.0
4.0 12 (40.0) 15 (50.0)
minimum – maximum 0.2 – 8.0 0.4 – 8.0 0.8 – 10.0
6.0 7 (23.3) 1 (3.3) percentile 5% 1.2 0.7 1.5
8.0 1 (3.3) 2 (6.7) percentile 95% 6.9 8.0 10.0
CI 95% [3.2; 4.5] [3.8; 5.2] [3.5; 5.5]
Angle between the medial
Table 4. Angle between the medial border and the vertical line of the
border and the vertical line
superior angle of the scapula: difference between the right and left sides (°). of the superior angle of the
Measurements – n (%) (n = 30) scapula – L Side (º)
-4.0 1 (3.3) mean (sd) 3.5 (1.7) 4.3 (2.1) 4.8 (3.2)
-2.0 6 (20.0) median 4.0 4.0 4.0
-0.2 1 (3.3) minimum – maximum 0.4 – 8.0 0.2 – 10.0 0.8 – 14.0
0.0 12 (40.0) percentile 5% 1.3 0.9 1.5
2.0 6 (20.0) percentile 95% 8.0 8.9 12.9
4.0 4 (13.3) CI95% [2.8; 4.1] [3.5; 5.1] [3.5; 6.0]
N.B.: No (0) individual (0%) with altered measurements, i.e. angle > 5°. SD – Standard Deviation / CI – Confidence interval.

The mean difference of the distances between the superior and the vertical line of the superior angle of the scapula on
angle of the scapula and the midline of the spinal column on the left side measured by examiner 1 and radiography was
the left side measured by examiner 1 and radiography was significantly different from 0 (p = 0.033) indicating larger mea-
significantly different from 0 (p = 0.011) indicating larger mea- surements taken by radiography. The mean values of the other
surements taken by radiography. differences were not significant compared to 0 (p > 0.05 in all
The mean difference of the angles between the medial border the comparisons).
210 Acta Ortop Bras. 2013;21(4):208-12
 Table 6. Inter-examiner reliability. Table 7. Validity of the evaluation method.
Evaluation Evaluation
Physical Physical Physical
Variables Difference Variables Difference
Examination – Examination – Examination – Radiography
Examiner 1 Examiner 2 Examiner 1
Vertical distance of the superior Vertical distance of the superior
angle of the two scapulae (cm) angle of the two scapulae (cm)
Mean (sd) 0.85 (0.69) 0.75 (0.52) 0.10 (0.56)
Mean (sd) 0.85 (0.69) 0.59 (0.38) 0.26 (0.66)
Comparison p = 0.319
Comparison p = 0.038 *
Concordance ICC = 0.73 p < 0.001 *
Concordance ICC = 0.48 p = 0.049 *
Distance between the superior
angle of the scapula and the Distance between the superior
midline of the spinal column – R angle of the scapula and the
Side (cm) midline of the spinal column – R
Side (cm)
Mean (sd) 9.1 (1.1) 9.3 (1.3) -0.24 (0.98)
Mean (sd) 9.1 (1.1) 9.2 (1.2) -0.14 (1.18)
Comparison p = 0.191
Comparison p = 0.522
Concordance ICC = 0.68 p < 0.001 *
Distance between the superior Concordance ICC = 0.67 p = 0.002 *
angle of the scapula and the Distance between the superior
midline of the spinal column – L angle of the scapula and the
Side (cm) midline of the spinal column – L
Mean (sd) 8.5 (1.2) 8.9 (1.4) -0.41 (1.02) Side (cm)
Mean (sd) 8.5 (1.2) 9.0 (1.3) -0.49 (0.99)
Comparison p = 0.035 *
Comparison p = 0.011 *
Concordance ICC = 0.69 p < 0.001 *
Angle between the medial border Concordance ICC = 0.65 p < 0.001 *
and the vertical line of the superior Angle between the medial border
angle of the scapula – R Side (º) and the vertical line of the superior
Mean (sd) 3.9 (1.8) 4.5 (1.8) -0.61 (2.25) angle of the scapula – R Side (o)
Comparison p = 0.151 Mean (sd) 3.9 (1.8) 4.5 (2.7) -0.62 (3.15)
Comparison p = 0.291
Concordance ICC = 0.38 p = 0.095
Concordance ICC = 0.12 p = 0.364
Angle between the medial border
and the vertical line of the superior Angle between the medial border
angle of the scapula – L Side (˚) and the vertical line of the superior
angle of the scapula – L Side (o)
Mean (sd) 3.5 (1.7) 4.3 (2.1) -0.84 (2.54)
Mean (sd) 3.5 (1.7) 4.8 (3.2) -1.28 (3.12)
Comparison p = 0.082
Comparison p = 0.033 *
Concordance ICC = 0.20 p = 0.263
SD – Standard Deviation / ICC - Intraclass Correlation Coefficient.
Concordance ICC = 0.39 p = 0.074

The ICC values for the measurements of the angle between the The study subjects were 30 healthy subjects, 17 women
medial border and the vertical line of the superior angle of the and 13 men, aged between 18 and 49 years, and the result
scapula on the right and left sides represent poor reproducibility obtained was that 73.3% of the participants presented scapular
of the measurements. positioning in the normal range established by Burkhart et al.9
The ICC values for the measurements of the vertical distance Inter-examiner reliability in our study was considered of poor
of the superior angle of the two scapulae and of the distance reproducibility for the measurements of the angle between the
between the superior angle of the scapula and the midline of the medial border and the vertical line of the superior angle of the
spinal column on the right and left sides represent satisfactory scapula on the right and left sides. For the measurements of
reproducibility of the measurements. the vertical distance of the superior angle of the two scapulae
and of the distance between the superior angle of the scapula
DISCUSSION and the midline of the spinal column on the right and left sides,
So far no regulations have been drafted concerning scapular the reproducibility is satisfactory.
positioning in healthy individuals during rest, and there is no Nijs et al.,2 in their study, used the test that measures the distance
method with clinical application able to provide measurements from the medial border of the scapula and the spinous process
related to the actual scapular kinematics. In addition, there is of the fourth thoracic vertebra, with the patient standing and with
the absence of standardization in the nomenclature used to the arms relaxed and also with the patients performing active
describe movements, planes and axes.2,10 scapular retraction. The inter-examiner reliability of this test, when
In this study, the static evaluation of the scapula was based on the conducted with the shoulders relaxed, was considered very low,
protocol described by Burkhart et al.,9 considering 1.5 cm or 5° of while the inter-examiner reliability with the test conducted with the
asymmetry as the abnormality threshold in each measurement, shoulders retracted was good.
thus classifying individuals with scapular dyskinesis. Nijs et al.2 also conducted the test of distance between the
Acta Ortop Bras. 2013;21(4):208-12
211
 posterior border of the acromion and the stretcher, in which the clinical examination compared to the radiographic examination,
examiner measures, with a measuring tape, the distance between we obtained poor reproducibility for the measurements of the
the acromion and the stretcher, bilaterally, and this study obtained angle between the medial border of the scapula and the vertical
inter-examiner reliability considered good, yet this measurement line of the spinal column on the right and left sides, while for
with the patient in dorsal decubitus can influence the scapular the measurements of the vertical distance of the superior angle
positioning, as the stretcher would stabilize the scapula correctly, of the two scapulae and of the distance between the superior
besides the fact that this position alters the effect of gravity on the angle of the scapula and the midline of the spinal column on
scapula. Kibler11 used the lateral scapula slide test as a means the right and left sides we observed merely satisfactory re-
of evaluation, and its inter-examiner reliability was considered producibility. We did not find excellent reproducibility in any of
good, yet the test is questionable, as it avoids impact positions, the measurements, demonstrating that there is a very strong
by maintaining positions below 90o, preventing inhibition of the probability of discordance between the measurements of the
musculature tested. The initial interpretation of this test indicates static clinical examination and of the radiography.
that as is the case in our study, a difference of more than 1.5 This study exhibited some limitations that may have influenced
cm between the two sides suggests the diagnosis of shoulder the results. The main limitation was in relation to the radio-
dysfunction, yet this difference of more than 1.5 cm between graphic examination, which was not carried out by the same
sides is frequently observed among asymptomatic individuals, technician, and although they followed a standard protocol,
corroborating the observations made in the present study and in there may have been changes in the angulation of the exams,
the study by Nijs et al.,2 Kliber11 and Meyer et al.12 thus altering their interpretation. Cote et al.13 showed that the
Due to the absence of regulations about scapular positioning ideal incidence for the performance of radiography to evaluate
in healthy individuals during rest, the present study sought by scapular positioning is with the individual upright, forming an
means of physical and radiographic examinations to obtain angle of 30o with the beam of the ray, thus parallel to the glenoid
the value of normality of scapular positioning on the rib cage and perpendicular to the scapula. It is not possible to guarantee
of healthy individuals. that all the radiographies were performed in this manner, which
In this study, 26.7 % of the participants presented scapular po- may hinder the identification of some scapular structures.
sitioning outside the range of normality established by Burkhart
et al.,9 as well as in the studies of Nijs et al.2 and Kibler,11 in CONCLUSIONS
which even asymptomatic individuals present some type of It was observed that 73.3% of the individuals presented
scapular dyskinesis.11,12 measurements within the established pattern of normality. The
It is worth keeping in mind that the static evaluation of scapular inter-examiner reproducibility of the static clinical examination
positioning is able to determine the presence of scapular dyski- was considered from poor to satisfactory. The reproducibility of
nesis, yet is not able to determine which disease this dyskinesis the static clinical examination with the radiographic examination
is associated with. In the reliability assessment of the static was considered from poor to satisfactory.

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