Manual Therapy 20 (2015) 124e129

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Manual Therapy
journal homepage: www.elsevier.com/math

Original article

Study of the trapezius muscle region pressure pain threshold and

latency time in young people with and without depressed scapula
Kuan-Ting Lee a, Chiung-Cheng Chuang a, *, Chien-Hung Lai b, c, Jing-Jhao Ye a,
Chien-Lung Wu d
a

Department of Biomedical Engineering, Chung-Yuan Christian University, Chung-Li, Taoyuan 320, Taiwan, ROC
Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan, ROC
Department of Physical Medicine and Rehabilitation, Taipei Medical University Hospital, Taipei 110, Taiwan, ROC
d
Division of Acupuncture, Linsen Chinese Medicine Branch, Taipei City Hospital, Taipei 110, Taiwan, ROC
b
c

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 2 October 2013
Received in revised form
10 July 2014
Accepted 22 July 2014

The scapula is stabilized in or moved to a certain position to coordinate shoulder function and achieve
shoulder and arm movement during the athletic and daily activities. An alteration in the scapular position both at rest and during arm movements is commonly associated with shoulder injury or
dysfunction. The purpose of this study was to assess the inuence of the depressed scapular position
using pressure pain threshold (PPT) and delayed muscle activation of the upper and middle trapezius
muscles. The study included 20 subjects who were divided into normal shoulder (n 12) and depressed
shoulder (n 8) group. PPT was measured in a relaxed position. Muscle activity was recorded using
surface electromyography and by calculating each shrug's muscle latency time (MLT). The results
revealed that the healthy young subjects with depressed scapular position had significantly lower PPT
levels than those with normal scapular position both in the upper and middle trapezius muscle
(P < 0.05). MLT of the upper trapezius was signicantly delayed in both sides during the shoulder shrugs
(P < 0.05).
2014 Elsevier Ltd. All rights reserved.

Keywords:
Scapula
Electromyography
Trapezius muscles
Pressure pain threshold

1. Introduction
Complex scapular, shoulder and arm movements are required to
allow the glenohumeral joint achieve the positions needed in daily
and athletic activities. These movements are maintained by tissue
support and muscle control that stabilizes the scapula, shoulder,
and arm in a certain position to accomplish motion (Tsai et al.,
2003; Di Giacomo et al., 2008), and the scapula plays an important role in the shoulder and arm function (Di Giacomo et al., 2008;
Kibler et al., 2009).
Several studies have illustrated the relationship between the
scapular position and synergic muscle pathology (Swift and
Nichols, 1984; Sahrmann, 2002; Kendall et al., 2005; Azevedo
et al., 2008), whereas in recent studies, researchers have explored

* Corresponding author. Department of Biomedical Engineering, Chung-Yuan

Christian University, 200 Chung Pei Road, Chung Li 32023, Taiwan, ROC.
Tel.: 886 3 265 4510; fax: 886 3 265 4599.
E-mail address: cheng965@cycu.edu.tw (C.-C. Chuang).
http://dx.doi.org/10.1016/j.math.2014.07.014
1356-689X/ 2014 Elsevier Ltd. All rights reserved.

healthy subjects with depressed scapular position (Azevedo et al.,

2008; Andrade et al., 2008).
The inuence of depressed scapular position on tissue sensitivity of the upper trapezius muscles and the relationship between
the scapular vertical position and active cervical rotation range-ofmotion were both investigated in previous studies. The relationship
between abnormal scapular kinematics and associated muscle
functions was however, not addressed by them. The paired trapezius muscles form a diamond shape that extend through the
midline from the occiput superiorly to T12 inferiorly, and posteriorly transverse throughout the spinal length of the scapula (Martini
et al., 2009). The scapula lies against the posterior thoracic cage
overlying the second to the seventh rib with the medial border
parallel to and about three ngers breadth from the middle of the
back and anteriorly rotated 30 to the frontal plane (Kesson and
Atkins, 2005; Saladin, 2007; Paterson, 2009). The three angles of
the scapula are the superior, inferior, and lateral angles (Saladin,
2007). The anterior surface is the subscapular fossa, and the posterior surface includes the spine, supraspinous fossa, and infraspinous fossa (Saladin, 2007). The scapula is held in place by
numerous muscles attached to the spine and fossae (Saladin, 2007;

K.-T. Lee et al. / Manual Therapy 20 (2015) 124e129

Martini et al., 2009). The scapula and trapezius are inter-related

because an abnormal scapular position may affect the function
and operation of the whole trapezius (Paterson, 2009). Therefore, it
is necessary to rene our knowledge on the relationship between
scapular dysfunction and muscle activation during the shoulder
movement period. Understanding the scapular and trapezius
function in shoulder related pathologies are therefore extremely
important for providing potential guidelines for interventions
aimed at improving the shoulder motion.
Surface electromyography (SEMG) is the use of electronic devices to measure the muscle energy, analyze the data and display
the results (Cram and Criswell, 2011). Compared with needle
electromyography, SEMG is a clinically easier, noninvasive, and less
sensitive technique (Pullman et al., 2000). Therefore, this technique
is commonly performed (Phadke et al., 2009) for the trapezius
muscles, which are the largest and most supercial scapulothoracic
muscles of the thoracic spine (Di Giacomo et al., 2008). The motor
system organizes and controls the skeletal muscle activation during
movement, posture, and the musculoskeletal aspect of behavior
and expression (Lederman, 2010). These motor control changes
may include a delayed activation or deactivation of the muscles,
which fails to be recruited on time (Phadke et al., 2009). In addition,
muscle latency time (MLT) is delayed when the shoulder muscles
are abnormally positioned during arm activities (Cools et al., 2002;
Moraes et al., 2008).
Pressure algometry has been widely used to assess sensitivity of
human tissues to mechanical stimuli (Blikstad and Gemmell, 2008;
Finocchietti et al., 2011) and has excellent reproducibility (Fabio
Antonaci, 1998). The effects of scapular position on the mechanical hypersensitivity of the upper trapezius muscles was recently
investigated (Azevedo et al., 2008). These experiments revealed
that subjects with depressed scapular position had lower upper
trapezius PPT levels than those with normal scapular position
(Azevedo et al., 2008). However, to the best of our knowledge, no
study to date has investigated the inuence of depressed scapular
position on the other regions of the trapezius muscles.
The purpose of this study was to investigate the inuence of
scapular position on both the mechanical properties and temporal
recruitment pattern of the upper and middle trapezius muscles e

125

relationship between the scapular position and trapezius muscles

using pressure pain threshold (PPT) and muscle latency time (MLT)
e in young healthy subjects.
In present study, it is supposed that healthy subjects with
depressed scapular position might have lower PPT levels in upper
and middle trapezius muscle position and delayed muscle activation timing while compared with subjects with normal scapular
position during the scapular motion.
2. Methods
2.1. Denition of scapular location
In this study, we established a discrimination procedure to
differentiate the scapular location and reduce articial deviations,
as shown in Fig. 1a and b. For the posture assessment, subjects were
directed to sit on a backless chair in a relaxed position with their
hands placed on their lap (Gemmell and Bagust, 2009). The scapular location was then conrmed
(Lewis
p
et al., 2002), and adhesive
round stickers (radius, r 1cm2 =p) were attached to both the
right and left shoulders, which involved the superior angle of the
scapula (SAS), lateral acromial border (LAB), and spinous process of
the second thoracic vertebra (SP2). The location of SP2 and LAB and
SAS was determined using previously reported methods followed
by Muscolino (2008) and Tixa (2008). Next, we erected a tripod
head and shelved a camera and laser level meter behind these
subjects. The laser height was centered on SP2 level. In addition, the
tables were reconrmed for no disproportion, and images were
recorded using a countdown trigger. A depressed scapular (DSC)
group placement was determined as a vertical SAS position and LAB
below the laser horizontal line. Neutral scapular (NSC) group position was determined when the two SASs and T2 can form a
straight line which is perpendicular to the spine (Fig. 1a and b).
2.2. Hardware design
2.2.1. Pressure threshold algometer
The electronic pressure algometer (FDX 25, WAGNER) was used
to assess the muscle pressure pain sensation, which consisted of a

Fig. 1. The scapular position: (a) Superior angle of the scapula on the same level as the T2 spinous process, (b) Superior angle of the scapula on the lower level as the T2 spinous
process.

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K.-T. Lee et al. / Manual Therapy 20 (2015) 124e129

round rubber disk (area, 1 cm2) to restrain the inuence of supercial skin stretching on the sensitivity of muscle pain (Finocchietti
et al., 2011). The pressure was measured in kilogram-force (kgf)
ranging 0e13 kgf/cm2 and a resolution of 0.01 kgf/cm2. The pressure value was recorded when the algometer was held perpendicular to the body, and the force was gradually increased until the
subjects' sense of pressure initially changed to pain (Fischer, 1987).
The mean of the rst three successive measurements was used to
determine the subjects' pressure pain threshold (PPT) level at each
test point site at a 30-s interval by the same examiner. This examination sequence closely followed that recommended by

ndez-de-las-Pen
~ as et al. (2007). Test point sites included both
Ferna
sides of the upper and middle trapezius muscles, and the measurement order included the left and right upper trapezius, and left
and right middle trapezius.
2.2.2. SEMG recording system
Muscle activation data for the upper and middle trapezius were
continuously and bilaterally recorded using an EMG signal amplier system (Power Lab 15T, ADInstruments). The power Lab 15T has
a sensitivity of 313 nV at an input range of 10 mV, differential
channels with common isolated ground, a noise level of <1 mV RMS
of 0.5e2 kHz, a 100 MU of input impedance, 24 bit 0.0006% FSR of
A/D resolution, and a common mode rejection ratio of 110 dB. These
attributes of instrumentation were recommended by Cram and
Criswell (2011). All data were displayed, recorded, and stored using the Lab Chart7 (ADInstruments) software. The sampling rate
was set at 1000 Hz per channel (Phadke et al., 2009). To reduce the
skin impendence, the skin surface was prepared with alcohol (Cools
et al., 2002; Picavet and Schouten, 2003).
Bipolar and disposable pre-gelled silveresilver chloride surface
electrodes (25 mm in diameter with 15 mm cavity that was lled
with electrolytic gel) were used with a constant interelectrode
distance of 3.5 cm over the upper and middle portions of the
trapezius muscles. Electrodes for the upper trapezius were placed
at the middle point of C7 spinous process and acromion (Cram and
Criswell, 2011). The middle trapezius electrodes were placed at the
middle point of T4 spinous process and medial border of scapular
spine (Cram and Criswell, 2011). A ground electrode was placed on
the seventh cervical vertebra C7. Before EMG data were recorded,
we ensured the presence of good electrical contact with the skin
surface to obtain stable signal.
3. Data analysis
3.1. Muscle latency time
The raw data were processed and analyzed using the LabVIEW
8.5 software (Laboratory Virtual Instrumented Engineering Workbench, National Instruments). Signals were then digitally full-wave
rectied and low-pass ltered (Butterworth, 6-Hz six-order).
Muscle latency was dened as the time needed for the muscles to
achieve 10% of rst maximum voluntary contraction from the
detection of time movement (Rozzi et al., 1999; Cools et al., 2002,
2003; De Mey et al., 2009).
4. Clinical testing

antidepressants or any analgesics for the last 3 months; (3) antiinammatory drugs for the previous 5 days (Azevedo et al.,
2008); (4) body-implanted electronic devices which interferes
with SEMG recording; (5) pain in the trapezius muscles. Each
subject was provided a verbal summary of the study design, and a
consent form was obtained prior to the participation. All recordings
were made in a secluded room at an ambient temperature of
approximately 25  C with the subjects in a sitting position, and the
analysis was performed by the same examiner. After dening the
scapular position, PPT was measured. The electrodes were then
attached to the skin to record EMG. Following a 3-min break during
which the subjects sat quietly, they were required to perform a
shrugging movements thrice, lifting the shoulders for 5 s each time
and then lowering them for another 5 s. A second 3-min break was
provided, followed by a second round of shrugging motions, and
each shrug's MLT of both the upper and middle trapezius was
calculated. Shrug1 and Shrug2 were the mean of the rst and last
three shrug's MLT, respectively. This study was approved by the
Institutional Review Board of the Taipei City Hospital.
5. Statistical analysis
The SPSS 12.0 (Statistical Package for Social Sciences for Windows 12.0) was used for statistical analyses. Data sets were tested
for normal distribution using the ShapiroeWilk test. The normal or
non-normal data distributions were respectively analyzed by an
Independent samples t-test, and the ManneWhitney test was used
to test the differences between the two groups. The signicant level
was set at P < 0.05. Data are presented as the mean SD throughout
the text. All data were analyzed by the same researcher, who was
not the examiner.
6. Results
The study sample included 20 right-handed subjects. Of these
subjects, 8 (5 males and 3 females) from the DSC group and 12 (5
males and 7 females) from the NSC group had mean SD ages of
21.7 0.7 years and 22.2 0.4 years, respectively. Subjects' characteristics are shown in Table 1.
Table 2 shows PPT of the DSC and NSC groups. The DSC group
demonstrated a lower mean PPT (P < 0.05) when compared to the
NSC group in both sides of the upper (right side mean
difference, 1.4 kgf; 95% condence interval (CI): 2.5 kgf
to 0.24 kgf and left side, P 0.011) and middle (right side mean
difference, 2.28 kgf; 95% CI: 4.32 kgf to 0.24 kgf and left side
mean difference, 2.17 kgf; 95% CI: 4.06 kgf to 0.27 kgf) trapezius muscles.
Table 3 presents the means and standard deviations for MLT
during the shoulder shrugs. During Shrug1, a signicant delayed
activation in the left upper trapezius was observed between the
DSC and NSC groups (mean difference, 88.83 ms; 95% CI:
16.18e161.68 ms). Although the right upper trapezius MLT of the
DSC group was more extended than the NSC group, the difference
was not signicant. During Shrug2, a signicant delayed activation

Table 1
Subjects' characteristics.

4.1. Subjects
The study included undergraduate students of Biomedical Engineering at the Chung Yuan Christian University in Chung Li,
Taiwan. Exclusion criteria included the following: (1) history of
orthopedic, neurological, or dermatological conditions of the cervical spine; (2) history of orthopedic conditions of upper limbs and

DSC group
NSC group

Age (years)

Weight (kg)

Height (cm)

Dominant
hand (R/L)

21.7 0.7
22.2 0.4

61.4 10.6
57.1 8.3

167.1 6.8
165.3 8.7

8/0
12/0

DSC: depressed scapular alignment; NSC: neutral position scapular alignment; R:

right; L: left.
Data are expressed as mean SD.

K.-T. Lee et al. / Manual Therapy 20 (2015) 124e129

Table 2
Pressure pain threshold (PPT) for the DSC and NSC groups.
Variables

Pressure pain threshold(PPT; kgf/cm2)

DSC group

RUT
LUT
RMT
LMT

3.27
2.90
4.17
3.77

0.8
1.1
1.4
1.3

NSC group

P value

0.021*,a
0.011*,b
0.030*,a
0.027*,a

4.68
4.41
6.45
5.94

1.3
1.2
2.4
2.2

DSC: depressed scapular alignment; NSC: neutral position scapular alignment; RUT:
right upper trapezius; LUT: left upper trapezius; RMT: right middle trapezius; LMT:
left middle trapezius.
Data are expressed as mean SD.
*P < 0.05 (2-tailed).
a
performed using the Independent samples t-test.
b
performed using the ManneWhitney test.

in the right and left upper trapezius was observed between the DSC
and NSC groups (right side, P 0.045 and left side mean difference,
89.93 ms; 95% CI: 17.66e162.13 ms).

7. Discussion

127

Before the PPT measurements, the muscles were already positioned

in a relaxed state. Therefore, Azevedo et al. (2008) hypothesized
that prolonged scapular depression would increase stress on the
tissues of the shoulder girdle. Moreover, Graven-Nielsen (2006)
and Finocchietti et al. (2011) suggested that pressure algometry is
mainly used to assess the pressure pain sensitivity of deep tissues.
Therefore, a depressed scapular position will reduce the mechanical stress on the deep tissues in the upper trapezius.
In our study, the DSC group demonstrated a decreased PPT
when compared to the NSC group on both sides of the middle
trapezius muscles. Azevedo et al. (2008) only assessed PPT for the
upper trapezius area, whereas Johnson et al. (1994) and Martini
et al. (2009) reported that the anatomy of the middle trapezius
muscles was connected with the scapula, and the middle fibers of
the trapezius muscles adduct the scapula with concentric
contraction or assist the rhomboid muscles to control scapular
abduction during eccentric contraction (Ekstrom et al., 2012).
Moreover, Di Giacomo et al. (2008) described that the scapula in a
non-ideal location will lead to the shoulder disease. These studies
indicate that subjects with depressed scapular position will affect
the upper and middle trapezius deep tissues, which have a lower
response to mechanical stress.

7.1. Pressure pain threshold

7.2. Muscle latency time
The study included young healthy subjects (mean SD age,
21 0.9 years) with pain-free trapezius muscles. The mean range of
these subjects' PPT ranged 2.90e6.54 kgf/cm2, which was similar to
that reported by Chesterton et al. (2003) in a wide age range
(mean SD age, 25 7 years). Besides, the mean range of PPT for
the healthy muscles was also closer to the result, greater than
30.5N/cm2, from Chesterton's study (Chesterton et al., 2003).
Azevedo et al. (2008) found that healthy young subjects (mean SD
age, 21.8 1.3 years) with depressed scapular position had lower
PPT levels (P 0.008, mean PPT, 19.0 N/cm2) in the upper trapezius
muscle region than subjects with normal scapular position (mean
PPT, 26.1 N/cm2). Our results, similar to the previous studies,
conrm that the DSC group demonstrated a lower mean PPT than
the NSC group on both sides of the upper trapezius muscles
although there were some differences in PPT measurement procedures and sample sizes between the two studies.
Azevedo et al. (2008) measured PPT three times with a 48-h
interval between each measurement. The rst and second measurements were performed by the same examiner, whereas the
third was by a different examiner. In our clinical measurement
process, a 5-min resting period was provided to the subjects to sit
in a relaxed position with their hands placed on their lap and both
arms resting in the neutral position between the PPT measurements. Simons et al. (1999) reported that healthy and painless
muscles will recover 70%e90% within a 1-min resting period.

Ekstrom et al. (2012) suggested that resting scapular position

may further cause lengthening or shortening of the axioscapular
muscles (trapezius, levator scapulae, rhomboid major, et cetera.),
which can have a direct effect on the scapular position on the
thoracic wall. Andriotti and von Piekartz (2007) suggested that
muscles adapt to the demands or restrictions placed on them and
protect the nervous system. Muscles become longer or shorter by
increasing or decreasing the number of sarcomeres in series.
Overloaded, they respond by increasing the number of sarcomeres
in parallel and amount of connective tissue proteins. They
concluded that a lengthened muscle can generate more tension
than a muscle of normal length, but could not control the joint
eccentrically through its entire range-of-motion (Andriotti and von
Piekartz, 2007). However, Andrade et al. (2008) reported that the
depressed scapular position in healthy young subjects does not
have a direct effect on cervical rotation range-of-motion when the
upper limbs were passively supported. To the best of our knowledge, no study has examined the relationship of the scapular position, trapezius muscle loading, and number of sarcomeres, and
therefore, further studies are required to examine this relationship
before the questions related to the topic are completely answered.
In our study, the upper trapezius muscle latency times were less
than observed by Cools et al. (2002) and Moraes et al. (2008)
perhaps as they observed different movement patterns, and age

Table 3
Muscle Latency Time for the DSC and NSC groups (in milliseconds).
Variables

Shrug1

Shrug2

DSC group
RUT
LUT
RMT
LMT

75.04
143.71
77.46
88.79

49.10
86.66
76.94
76.89

NSC group
58.08
54.78
36.81
51.50

22.31
200.20
18.47
26.54

P value
a

0.306
0.023*,a
0.355b
0.280b

DSC group
129.83
157.63
84.13
99.00

108.37
85.83
76.28
76.27

NSC group
64.11
67.72
47.81
61.11

40.40
24.55
23.89
48.95

P value
0.045*,b
0.021*,a
0.758b
0.335b

DSC: depressed scapular alignment; NSC: neutral position scapular alignment; RUT: right upper trapezius; LUT: left upper trapezius; RMT: right middle trapezius; LMT: left
middle trapezius.
Data are expressed as mean SD.
*P < 0.05 level (2-tailed).
a
performed using the Independent samples t-test.
b
performed using the ManneWhitney test.

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K.-T. Lee et al. / Manual Therapy 20 (2015) 124e129

group of 18e35 years in their studies. In our exercise, all subjects

were required only to shrug, and the limb was not stretched during
the required movement of investigation the inuence of fatigue and
pain for normal subjects during the MLT shoulder movements was
examined. However, this inuence has led to delayed MLT in the
trapezius in their studies (Cools et al., 2002; Moraes et al., 2008).
This delay may be the result of muscle ber loss >25 years old
(Powers and Howley, 2004). In our study, all subjects were <23
years, and SD < 1 year, which reduced the aging inuence of the
muscle ber contents.
These results indicate that there was a statistically signicant
delay in the left upper trapezius MLT in subjects with depressed
scapular position as compared to subjects with normal scapular
vertical position in Shrug1. However, the NSC group's standard
deviation was extremely high to detect a statistically signicant
difference between NSC and DSC on the left upper trapezius MLT of
Shrug1. However, in Shrug2, the upper trapezius had a statistically
signicant delay between NSC and DSC on both sides. To enhance
the stability of the scapular movement on the chest wall, an
appropriate torque was provided by the trapezius (Di Giacomo
et al., 2008). Although the underlying movement parameters are
changed, the action would be completed, but will have different
motor programs (Lederman, 2010). Furthermore, slight variations
in the underlying posture/position during the movements will
change the overall patterns of muscle recruitment (Lederman,
2010). Comerford and Mottram (2001) suggested that muscle
dysfunction will result in motor control decit associated with
delayed timing or recruitment deciency. Kendall et al. (2005)
found that when the scapula has a lower horizontal position, the
upper trapezius have different patterns to elevate the scapula. From
these studies, we hypothesized that the delayed MLT of the DSC
group is the result of adaptation of the upper trapezius to a
different supply/recruitment model to maintain the stability of the
shrug process. However, further research is required.
Azevedo et al. (2008) suggested that a position of scapula
depression would place the supportive tissues of the shoulder
girdle, including muscles, in a lengthened position. When skeletal
muscle is too stretched or compressed the cross-bridge structures
will be affected and restrain the forces that can be produced (Jones
et al., 2004; Rosenbaum, 2010; Cram and Criswell, 2011). Moreover,
the speed at which a muscle can contract is primarily limited by the
rate of cross-bridging at the sarcomere level (Cram and Criswell,
2011). In a previous review, Phadke et al. (2009) reported that
delayed activation in the motor control timing of the scapular
muscles is associated with various shoulder related pathologies.
Therefore, it fails to be recruited on time. The results of this study
suggested that the DSP group may increase stress, lengthen of deep
tissues in the trapezius region, and inuence response to mechanical stress such that have lower PPT values. These causes may
affect part of the cross-bridge structures in the trapezius region and
delay MLT. However, further studies are needed to verify above
hypothesis.
For clinical examination, the identication of scapular
dysfunction and dyskinesis is of primary importance (Kendall et al.,
2005; Kibler et al., 2009, 2013). Kibler et al. (2013) reported that
altered scapular motion and position have been termed scapular
dyskinesis and suggested that shoulder impingement symptoms
appeared to be affected by scapular position and motion. People
with shoulder impingement showed an increased trapezius muscles asymmetry (Warner et al., 1992) and a lower posterior tilting
angle of the scapula in the sagittal plane while compared with
nonimpaired subjects (Lukasiewicz et al., 1999). Furthermore, a
number of studies found a signicant delayed trapezius muscles
onset in subjects with shoulder impingement (Cools et al., 2003;
Phadke and Ludewig, 2013; Worsley et al., 2013). Simons et al.

(1999) suggested that muscle trigger point could play a relevant

role in shoulder impingement syndrome and muscle with trigger
point may reduce the response to mechanical stress. For these
reasons, it was supposed that reduced PPT, delayed EMG latency, or
improper scapula position would play a relevant role in shoulder
impingement symptoms in present study. However, further
research is required to verify this hypothesis. Previous studies have
shown that healthy young adults with depressed scapular position
may implicate muscle sensitivity (Azevedo et al., 2008), but not
inuenced the active range-of-motion of cervical rotation (Andrade
et al., 2008). Overhand athletes with impingement symptoms has
been shown related to delayed onset of contraction in the middle
and lower parts of the trapezius muscle (Cools et al., 2003). The
current ndings may be helpful to understand the relationship
between abnormal scapular position and delayed onset of muscle
activation and provided further evidence that depressed scapular
could lead to delayed MLT. Therefore, this study is useful to explore
the role of scapular position in shoulder dysfunction and appropriate rehabilitation intervention should consider improving
movement patterns and muscle control for overhand athletes in
future.
7.3. Limitations
There are additional limitations of this study. First, EMG was
measured only during the shoulder shrug. However, the shoulder
shrug movement requires more force from the upper trapezius
than the middle trapezius (Cram and Criswell, 2011). Therefore,
further studies are necessary to provide details regarding the
function of the middle trapezius MLT. Secondly, the current study
provided preliminary data of pressure pain threshold and muscle
latency time of the trapezius muscles in a relatively small number
of asymptomatic young subjects. This research was a pilot study.
We recruited subjects from a small, healthy population. Furthermore, we used fairly strict exclusion criteria and similarly
controlled for subject ages. Only 20 volunteers (8, DSC and 12, NSC)
met the experimental conditions. A study focusing on a larger
number of participants, including those with shoulder pain, is likely
to provide more information for use in clinical practice. Thirdly,
both time and frequency can be analyzed from the EMG data and
the present study only analyzed the time phase. Many studies have
used spectrum analysis to explore the relationships between fatigue response and muscle ber type of the shoulder muscles
(Minning et al., 2007; Candotti et al., 2009). Further investigations
to analyze the spectrum algorithms of EMG signal could gain more
information about the inuence of scapular position on muscle
fatigue and ber types of the trapezius muscle region. Finally, a
three-dimensional (3D) kinematics measurement technique has
been shown to be a very powerful tool to assess shoulder motion,
which could be utilized to clarify the relationship between real
scapular position and muscle function around the scapula during
motion (Kibler et al., 2013; Morais and Pascoal, 2013).
8. Conclusions
The results revealed that pain-free young subjects had lower
PPT levels in the upper and middle trapezius muscles in depressed
scapular position compared to those in normal scapular position.
According to the resultant phenomena of the experiment, upper
trapezius muscle control may have delayed recruitment during
shoulder shrugs. We included case reports only if they contributed
new information about characteristics, diagnosis or treatment of
the disease. Clinicians may use this information to further explore
the relationship between the scapular position and trapezius
muscle function. Further studies are required to evaluate the

K.-T. Lee et al. / Manual Therapy 20 (2015) 124e129

inuence of scapular vertical position on the mechanisms of

shoulder muscles.
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