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Journal of Athletic Training 2009;44(2):160–164

g by the National Athletic Trainers’ Association, Inc
www.nata.org/jat
original research

A Clinical Method for Identifying Scapular Dyskinesis,
Part 1: Reliability
Philip McClure, PhD, PT*; Angela R. Tate, PhD, PT*; Stephen Kareha, DPT, PT,
ATC, CSCS`; Dominic Irwin, DPT, PT‰; Erica Zlupko, DPT, PTI
*Arcadia University, Glenside, PA; 3H/S Therapy Associates Inc, Lower Gwynedd, PA; 4Go Sport Physical Therapy,
Gettysburg, PA; 1MedCentral Health System, Shelby, OH; IPhysical Therapy@ACAC, Charlottesville, VA

Context: Shoulder injuries are common in athletes involved frontal-plane abduction. Videotapes from randomly chosen
in overhead sports, and scapular dyskinesis is believed to be participants were subsequently viewed and independently rated
one causative factor in these injuries. Many authors assert for the presence of scapular dyskinesis by 6 raters (3 pairs), with
that abnormal scapular motion, so-called dyskinesis, is related each pair rating 30 different participants. Raters were trained to
to shoulder injury, but evidence from 3-dimensional measure- detect scapular dyskinesis using a self-instructional format with
ment studies regarding this relationship is mixed. Reliable and standardized operational definitions and videotaped examples of
valid clinical methods for detecting scapular dyskinesis are normal and abnormal motion.
lacking. Main Outcome Measure(s): Scapular dyskinesis was de-
Objective: To determine the interrater reliability of a new test fined as the presence of either winging or dysrhythmia. Right
designed to detect abnormal scapular motion. and left sides were rated independently as normal, subtle, or
Design: Correlation design using ratings from multiple pairs obvious dyskinesis. We calculated percentage of agreement
of testers. and weighted kappa (kw) coefficients to determine reliability.
Setting: University athletic training facilities. Results: Percentage of agreement was between 75% and
Patients or Other Participants: A sample of 142 athletes 82%, and kw ranged from 0.48 to 0.61.
(from National Collegiate Athletic Association Divisions I and III) Conclusions: The test for scapular dyskinesis showed
participating in sports requiring intense overhead arm use. satisfactory reliability for clinical use in a sample of overhead
Intervention(s): Participants were videotaped from the athletes known to be at increased risk for shoulder symptoms.
posterior aspect while performing 5 repetitions of bilateral, Key Words: shoulder, upper extremity, kinematics, assess-
weighted (1.4-kg [3-lb] or 2.3-kg [5-lb]) shoulder flexion and ment

Key Points
N Trained athletic trainers and physical therapists can recognize and distinguish between abnormal scapular movement
patterns and normal patterns in young, athletically active adults.
N The scapular dyskinesis test provides a reliable method for clinical examination of overhead athletes.

V
isible alterations in scapular position and motion evaluation, clinical assessment of scapular motion has
patterns have been termed scapular dyskinesis1 and proven challenging because of both the extensive soft tissue
are believed to occur as a result of changes in covering the scapula and the complex 3-dimensional (3-D)
activation of the scapular stabilizing muscles2; damage to patterns of motion that occur with shoulder use. Abnormal
the long thoracic, dorsal scapular, or spinal accessory scapular mechanics are present among some persons with
nerves; or possibly reduced pectoralis minor muscle subacromial impingement and shoulder instability, yet a
length.3 Scapular dyskinesis has been associated with validated, clinically feasible method of identifying scapular
shoulder injury, and several groups have found differences dysfunction is lacking.1,4,7
in scapular kinematics among people with instability, Clinical measures of scapular position based on side-to-
rotator cuff tears, and impingement syndrome when side differences of linear measures (from the spine to the
compared with healthy shoulders, although the magnitude medial border of the scapula) have lacked reliability,8,9 and
of differences between symptomatic and asymptomatic measures of linear asymmetry in athletes may not indicate
individuals is typically very small.1,2,4–6 Visually, findings dysfunction.10 Additionally, linear measures taken at static
of dyskinesis have been reported as winging or asymme- arm positions fail to capture the 3-D motion patterns present
try.1 To develop definitive conclusions about the role of during dynamic upper extremity movement, as in overhead
scapular kinematics in those with shoulder injury and to occupational activity or sports. Warner et al1 found that
identify a potential subset related to abnormal scapular scapular abnormalities were more evident during dynamic
motion patterns, clinical methods to distinguish normal assessment than during static testing in participants with
and abnormal scapular motion are needed. impingement and instability. Kibler11 suggested that mild
Although assessing the scapulothoracic articulation is scapular dyskinesis is more frequently evident during the
considered an essential component of the shoulder lowering phase of arm movement, presumably because of the

160 Volume 44 N Number 2 N April 2009

elbows straight. and were videotaped from both superior and targeted at scapular control. depending on their no way of identifying which patients need interventions height. volunteers under- 28). or After the tester demonstrated the movements. A total of 142 part of the face visible. researchers trying to posterior views.31 for interrater reliability between the 2 physical therapists and the 2 physicians.altered neuromuscular control required during eccentric muscle contraction. CA) were used to videotape weighing 68. Before testing. Visual assessment offers an alternative to linear measures for evaluating 3-D scapular motion in a practical clinical method that incorporates dynamic upper extremity tasks that require both raising (concentric) and lowering (eccentric) phases. respectively. Exclusion weighted shoulder flexion and bilateral. clinicians have teers stood 2 to 3 m from the camera. symmetric scapular motion was considered type IV. both in real time and with buttocks to the anterior aspect of the scalp without any videotaped segments viewed at a later date. Tests were performed with volunteers grasping dumbbells Instrumentation according to body weight. An extension arm was attached to the understand the relationship between scapular dyskinesis camera stand to obtain the superior view. reliable method of deter. San Diego. swimming (n 5 19).42 and 0. active. tennis. active. 2 30. These weights were chosen Journal of Athletic Training 161 . and elbows through the full range of motion. However. These 2 represents the worst pain possible. allergy to adhesives. Investigators adjusted the camera’s lens so that the METHODS posterior view included each volunteer’s waist. or body mass index $ body.13–16 The athletes’ sports included water allow observation of the posterior thorax. After completing polo (n 5 89). Volun- mining the presence of scapular dyskinesis.1 kg or more. reliable visual analysis of Figure 1. range of motion. Normal. glenoid labral tear. scapular dysfunction may be possible. with 93 including special tests. after viewing several participants. The videotapes were viewed and rated by 2 physicians and 2 physical therapists. Set-up of participant and cameras for videotaping. Testing began with arms at the side of the past 30 days. 2 to 3 m away. This population was selected because of the high incidence of shoulder injury reported Male participants were asked to remove their shirts and among athletes participating in sports requiring overhead females were asked to wear halter tops during the study to use of the arm. each III level. head. Similarly. was to determine the interrater reliability of a newly However. test movements to be included in the study. Volunteers (n 5 26) were videotaped from behind during arm elevation in the frontal and scapular planes. Study participants were required to complete all participant performed 5 repetitions of bilateral. fracture. baseball/softball (n 5 demographic and self-report measures.3 kg (5 lb) for those of America. athletes competing in a National Collegiate Athletic Association sport that required repetitive overhead activity Experimental Procedure were recruited for this study. the shoulder surgery within the past year. Participants approved by the Arcadia University and Temple University were asked to simultaneously elevate their arms overhead institutional review boards. athletes were females and 111 were males. which also approved the study. The purpose of our study consistent setup throughout the data collection process. and type III 5 excessive superior border elevation. weighted criteria were a current pain rating of 7/10 or greater on a shoulder abduction (frontal plane) while they were video- numeric rating scale where 0 represents no pain and 10 taped from the posterior and superior views. loaded tasks. the authors suggested that with refinement.4 kg (3 lb) for those weighing Two video cameras (model 8 DCR-TRV730. n 5 6). and the and shoulder injury would benefit from a simple method of mounting points were marked in order to maintain a identifying those with dyskinesis. Without a clinically feasible. Sony Corp less than 68.0. Kappa coefficients were 0. and isometric competing at the Division I level and 49 at the Division strength measures. participants and play back the recorded segments. in the final assessment (Figure 1). In addition to these tests. shoulder dislocation. which are rather low to support the use of their system.1 kg (150 lb) and 2. all volunteers signed a consent form testers observed from the back. and shoulders in neutral rotation. type II 5 medial border prominence. For the superior We used a single-session measurement design with view. history of direct volunteers were instructed and briefly practiced each contact injury to the neck or upper extremities within the movement. Kibler et al12 reported the reliability of a visually based classification system for scapular dysfunction that defined 3 different types of motion abnormalities: type 1 5 inferior angle prominence. the camera was adjusted to include the posterior multiple rater assessments. Thirty-one went a physical examination by a certified athletic trainer. we judged the developed scapular dyskinesis test (SDT) that is visually superior view unnecessary and only used the posterior view based and uses dynamic. and other (eg. volleyball. 1. a history of rotator cuff or weighted elevation tests constituted the tasks for the SDT. as far as possible to a 3-second count using the ‘‘thumbs- up’’ position and then lower to a 3-second count.

we deliberately did not provide individual not considered in the analysis of this study. and representative volun.Table 1. along with the maximum possible k of the judgments of the other raters. The agreement among live physical therapists with 7–20 years’ experience) indepen. Percentage of resistance more often resulted in abnormal scapular motion agreement and weighted k were calculated among the live than static tests in those with shoulder injury. subtle dyskinesis. Additionally. or obvious dyskinesis.19 To avoid written operational definitions and rating scale used for violating the assumption of independence. if requested. RESULTS For the ‘‘live’’ rating. the maximum k possible was www. classifying scapular motion as normal. raters for all 142 participants and for the 3 pairs of videotape All examiners underwent standardized training via a self. Each rater then independently rated the test 0. Data teers are shown in Figure 2.42 and 0.20 These results are better than those permitted until all videos were rated. At a later time. subtle dyskinesis. not consistently present c) Obvious abnormality: striking. evident on at least 3/5 trials (dysrhythmias or winging of 1 in [2. 6 raters who were preserving the proportions of positive ratings demonstrat- not investigators (3 separate pairs consisting of 2 certified ed by each clinician’’19 and. The calculated as suggested by Sim and Wright. including those both motions were rated normal or 1 was judged normal and with mild to moderate symptoms. reliabilities for training are shown in Table 1. therefore. clearly apparent abnormality. 90. 162 Volume 44 N Number 2 N April 2009 .edu/academic/default. Subtle abnormality: Both flexion and abduction are rated as having subtle abnormalities.12 who also used a visually based system and reported k coefficients of 0.aspx?id515080). or rapid downward rotation during arm lowering. then smoothly and continuously rotates upward during elevation and smoothly and continuously rotates downward during humeral lowering. subtle.54 cm] or greater displacement of scapula from thorax) Final rating is based on combined flexion and abduction test movements. range of motion. the k statistic can be artificially low with inadequate tions.54 for those viewing videotape) in movements for each shoulder as having normal motion. the rating was obvious dyskinesis.arcadia. No discussion was obvious dyskinesis. Kibler et al12 required a test movements: normal. ie. 30 different participants for each pair) on a large screen.57 for live raters and 0. nonsmooth or stuttering motion during arm elevation or lowering. it was value for the given data. Raters were permitted to view a test movement for a DISCUSSION second time. may provide a more athletic trainers with 1–2 years’ experience and 4 licensed meaningful reference value. as we believe that the subtypes percentage of agreement and weighted k (linear weighting) defined by Kibler et al are not mutually exclusive categories based on 3 possible ratings from the flexion and abduction and often occur simultaneously. Dysrhythmia: The scapula demonstrates premature or excessive elevation or protraction. can repetitively lift these the other. in order to simulate a clinical situation in which a therapist could ask a patient to repeat a We found moderate interrater reliability (average kw 5 motion. the final rating was movements were based on the findings of a pilot study17 subtle dyskinesis. Test both were judged as subtle dyskinesis. and if either test motion was rated obvious and Johnson18 that showed active movements with dyskinesis. Winging: The medial border and/or inferior angle of the scapula are posteriorly displaced away from the posterior thorax. Obvious abnormality: Either flexion or abduction is rated as having obvious abnormality. Scapular dyskinesis: Either or both of the following motion abnormalities may be present. Our system did not attempt to distinguish among Interrater reliability for the SDT was described using subtypes of dyskinesis. raters viewing 30 participants each. but they often became aware are shown in Table 2. if amounts through their full available range of motion. Visual ratings were determined at the time of testing and also at a later time by viewing video recordings. because instructional slide presentation including operational defini. Scapular Dyskinesis Test: Operational Definitions and Rating Scale Operational Definitions Normal scapulohumeral rhythm: The scapula is stable with minimal motion during the initial 306 to 606 of humerothoracic elevation. The ratings of single forced choice among 4 categories. training. Normal: Both test motions are rated as normal or 1 motion is rated as normal and the other as having subtle abnormality. No evidence of winging is present. Therefore. based on pilot data indicating that athletes. To enhance the generalizability related to special tests. the final rating was normal. and embedded video examples (http:// variation in the data. photographs. or subtle dyskinesis. Maximum k values were reported possible for the investigators to learn the tendencies of other since they ‘‘gauge the strength of agreement while raters during the study. and strength were of our findings. including 3 flexion and abduction motions were combined such that if subtypes of dyskinesis: type 1 5 inferior angle prominence. reported by Kibler et al. the left and right sides were calculated separately. or obvious. 2 of the 5 investigators (a certified athletic trainer and a licensed physical therapist or physical The percentage of agreement and k coefficients for the therapy student) observed and independently rated the SDT for both the live ratings and the videotaped ratings athletes at the time of testing.32 for interrater reliability among physical therapists and physi- Data Analysis cians. Rating Scale Each test movement (flexion and abduction) rated as a) Normal motion: no evidence of abnormality b) Subtle abnormality: mild or questionable evidence of abnormality. ratings by the investigators was slightly higher than among dently viewed randomly selected videotaped athletes (n 5 the raters viewing the videotaped athletes.

adults can be visually recognized and distinguished from normal patterns with satisfactory reliability by trained type II 5 medial border prominence. type III 5 excessive athletic trainers and physical therapists using the SDT. The scapular Taken collectively. as they most frequently provoked abnormal motion and were thought to better reproduce daily activities of workers. Our current approach to treating scapular dyskinesis does not vary based on the specific type of dysfunction (dysrhythmia or winging) or affected test motion (flexion or abduction). Using only written descriptions to define a dynamic motion abnormality is inherently limiting. This provides further evidence that the rating of dyskinesis should not be based on measures of asymmetry. In a study of 71 collegiate athletes with this population in the future. Of the 142 volunteers rated. The scapular motion pattern was rated as normal. and type IV 5 symmetric test represents a reliable and feasible method for clinical scapular motion (normal). We determined a single rating based on observation of flexion and abduction tasks and allowed observation of either dysrhythmia or winging to identify dyskinesis. we used videotaped examples to help further define normal and abnormal motion. We believe this simplified approach is appropriate because the primary treatment decision is simply whether or not to address scapular dyskinesis in a treatment program with scapular exercises and other strategies such as taping or bracing.1. Their method seemed to focus examination of overhead athletes.21–23 Muscular fatigue may directly affect scapulohumeral rhythm. which have been shown to alter scapular kinematics. Our raters were instructed not to focus on side-to-side comparisons but rather on absolute scapular position and motion relative to the thorax. at least 1 rater observed obvious dyskinesis in 29 left shoulders and 25 right shoulders. athletically active and subtle dyskinesis on the right. and 32 had obvious dyskinesis bilaterally. Participants performing flexion with dumbbell. They identified participants with both unilateral and bilateral abnormalities. For weighted abduction. primarily winging. Journal of Athletic Training 163 . CONCLUSIONS Figure 2. who participated in 1-arm–dominant sports. The superior border elevation.12 Although we believe this system would asymmetry and may have led to rater confusion. B.5. raters were instructed to rate each scapula indepen. and the reliability was on detecting asymmetric motion patterns. More specifically. homemakers. In our most likely also prove reliable in a clinical setting with study. A. At least 1 rater observed obvious dyskinesis in 45 left shoulders and 46 right shoulders of 142 participants (284 shoulders) rated visually at the time of testing during weighted flexion.5 cm on 1 or more of the 3 positions assessed for the lateral scapular slide test. the SDT should be studied dently of the other side. our findings suggest that abnormal motion pattern was rated as having obvious dyskinesis on the left scapular movement patterns in young. and athletes. 37 had obvious dyskinesis on the right. therefore. Koslow et al10 found that 52 exhibited a difference of at least 1. resulting in compensatory increased rotation or destabilization of the scapula.17 we retained only the weighted tests.12 We also believe that standard- ized training using videotaped examples of normal and abnormal motion was an important feature of this study and improved reliability. They concluded that measures of asymmetry in athletes do not indicate dysfunction. as suggested by others. weighted flexion was the motion that most commonly resulted in dyskinesis. patients seeking medical care. Our method also included loaded tasks. although their better than that for a previously described visual classifi- descriptions of dyskinesis did not seem to demand cation system.23 which suggests the need to assess conditions when resistance to the arm is applied. Although preliminary testing with this classification system involved active and resisted movements.11. 52 had obvious dyskinesis on the left.

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