Accepted Manuscript

Influence of Pectoralis Minor and Upper Trapezius Lengths on Observable Scapular

Dyskinesis

Sevgi Sevi YEŞİLYAPRAK, PT, PhD, Ertuğrul YÜKSEL, PT, Msc, Serpil KALKAN,
PT, Msc

PII: S1466-853X(15)00066-8
DOI: 10.1016/j.ptsp.2015.08.002
Reference: YPTSP 677

To appear in: Physical Therapy in Sport

Received Date: 19 April 2015

Revised Date: 20 July 2015
Accepted Date: 14 August 2015

Please cite this article as: YEŞİLYAPRAK, S.S., YÜKSEL, E., KALKAN, S., Influence of Pectoralis Minor
and Upper Trapezius Lengths on Observable Scapular Dyskinesis, Physical Therapy in Sports (2015),
doi: 10.1016/j.ptsp.2015.08.002.

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to
our customers we are providing this early version of the manuscript. The manuscript will undergo
copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please
note that during the production process errors may be discovered which could affect the content, and all
legal disclaimers that apply to the journal pertain.
 ACCEPTED MANUSCRIPT

1 Influence of Pectoralis Minor and Upper Trapezius Lengths on Observable

2 Scapular Dyskinesis
3

4 Sevgi Sevi YEŞİLYAPRAK, PT, PhD1

1
5 School of Physical Therapy and Rehabilitation, Dokuz Eylul University.

PT
6 Postal address: Dokuz Eylul Üniversitesi, Fizik Tedavi ve Rehabilitasyon Yüksekokulu,
7 İnciraltı Sağlık Yerleşkesi, TR-35340, Balçova- Izmir, Türkiye

RI
8 e-mail: ssyesilyaprak@gmail.com, sevgi.subasi@deu.edu.tr

SC
9 Ertuğrul YÜKSEL, PT, Msc1
1
10 School of Physical Therapy and Rehabilitation, Dokuz Eylul University.

11
U
Postal address: Dokuz Eylul Üniversitesi, Fizik Tedavi ve Rehabilitasyon Yüksekokulu,
AN
12 İnciraltı Sağlık Yerleşkesi, TR-35340, Balçova- Izmir, Türkiye

e-mail: er-tugrl@hotmail.com
M

13

14 Serpil KALKAN PT, Msc1

D

1
15 School of Physical Therapy and Rehabilitation, Dokuz Eylul University.
TE

16 Postal address: Dokuz Eylul Üniversitesi, Fizik Tedavi ve Rehabilitsyon Yüksekokulu,

17 İnciraltı Sağlık Yerleşkesi, TR-35340, Balçova- Izmir, Türkiye
EP

18 e-mail: s_yuksel_24@hotmail.com
C

19
20 Address correspondence to Sevgi Sevi YEŞİLYAPRAK (Corresponding author),
AC

21 Postal address: Dokuz Eylül Üniversitesi, Fizik Tedavi ve Rehabilitasyon Yüksekokulu,

22 İnciraltı Sağlık Yerleşkesi, Balçova 35340, İzmir, TÜRKİYE
23 e-mail: ssyesilyaprak@gmail.com, sevgi.subasi@deu.edu.tr
24 Phone number: +902324124926
25
26 The study protocol was approved by the Dokuz Eylul University Ethics Committee. The
27 authors certify that they have no affiliations with or financial involvement in any

1
 ACCEPTED MANUSCRIPT

28 organization or entity with a direct financial interest in the subject matter or materials
29 discussed in the article.
30
31 Funding: We affirm that we have no financial affiliation (including research funding)

32 or involvement with any commercial organization that has a direct financial interest in

PT
33 any matter included in this manuscript.

RI
34 Declaration of Interest Statement: The authors declare that they have no conflict of

35 interest.

U SC
AN
M
D
TE
C EP
AC

2
 ACCEPTED MANUSCRIPT

1 Influence of Pectoralis Minor and Upper Trapezius Lengths on Observable

2 Scapular Dyskinesis

4 ABSTRACT

PT
5 Objectives: Although a relationship between short pectoralis minor and upper trapezius

6 and scapular dyskinesis has been postulated, no studies have investigated this theory.

RI
7 Understanding the effect of these muscle lengths on observable scapular dyskinesis may

SC
8 aid in determining risks and therefore making treatment decisions. Being aware of the

9 magnitude of this effect would help gauge the significance of risks involved. Our aim

10
U
was to evaluate the influence of pectoralis minor and upper trapezius lengths on
AN
11 scapular dyskinesis.

12 Design: Cross-sectional study

M

13 Setting: University research laboratory

D

14 Participants: Asymptomatic participants (n=148;296 arms) were evaluated.

TE

15 Main outcome measures: Scapular Dyskinesis Test (SDT) was used to identify

16 scapular dyskinesis, Pectoralis Minor Index (PMI) and Upper Trapezius Length Testing
EP

17 were used to determine muscle length.

18 Results: SDT+ arms had shorter pectoralis minor resting length (PMI:7.49±0.38)
C

19 (p<0.001) and greater incidence of short upper trapezius (ISUT) (66.7%) (p<0.001)
AC

20 compared to SDT- arms (PMI:8.58±0.75, ISUT:22.5%). With each decrease in PMI, the

21 likelihood of having scapular dyskinesis increased 96% (p<0.001). Arms with short

22 upper trapezius were 2.049 times more likely to exhibit scapular dyskinesis than those

23 with normal length (p=0.042).

3
 ACCEPTED MANUSCRIPT

24 Conclusions: Having a shorter pectoralis minor and upper trapezius length substantially

25 increased the likelihood of having visually observable scapular dyskinesis.

26

27 HIGHLIGHTS

PT
28 We investigated the influence of muscle length on scapular dyskinesis.

29 We determined to what extent possible predictors for this case are.

RI
30 The shorter the pectoralis minor, the more likely the arm has scapular dyskinesis.

SC
31 Upper trapezius shortness increases the likelihood of exhibiting scapular dyskinesis.

32 Routine assessment of these muscle lengths in scapular examination is recommended.

33
U
AN
34 KEY WORDS

35 Scapula, Shoulder, Biomechanics/upper extremity

M

36
D

37
TE

38

39
EP

40

41
C

42
AC

43

44

45

46

47

4
 ACCEPTED MANUSCRIPT

48 INTRODUCTION

49 Proper positioning and movement of the scapula on the thorax is crucial for effective

50 shoulder position, motion, stability and muscle performance. The scapula plays several

51 important roles for normal shoulder function. These include forming a link between the

PT
52 humerus and axial skeleton and serving as an attachment site for the rotator cuff and

53 scapulothoracic muscles. Coordinated movement of the scapula and humerus, known as

RI
54 scapulohumeral rhythm, is needed during upper extremity movements (Cools et al.,

SC
55 2014; Kibler et al., 2013; Kibler & Sciascia, 2010). In individuals without shoulder pain

56 or dysfunction, the scapula upwardly rotates, tilts posteriorly and rotates internally or

U
57 externally during humeral elevation, whereas decreased upward rotation and posterior
AN
58 tilting, and increased internal rotation has been found in those with shoulder

59 impingement (Borstad & Ludewig, 2005; Forthomme, Crielaard, & Croisier, 2008;
M

60 Ludewig & Reynolds, 2009; Lukasiewicz, McClure, Michener, Pratt, & Sennett, 1999).
D

61 Alterations in scapular kinematics such as changes in the normal position or any

TE

62 abnormal motion pattern of the scapula during active motions have been termed

63 “scapular dyskinesis” (Kibler et al., 2013). This impairment may be related to changes
EP

64 in bony posture or injury, muscle weakness/imbalances, muscle inflexibility

65 (shortness/tightness) or pain (Cools et al., 2014; Kibler et al., 2013; Kibler & Sciascia,
C

66 2010; Kibler & McMullen, 2003; Kibler, Sciascia, & Wilkes, 2012; Ludewig &
AC

67 Reynolds, 2009; Manske, Reiman, & Stovak, 2004). Muscle inflexibility specifically

68 has been theorized to play an important role in scapular motion, as it can influence both

69 the position and movement patterns of the scapula. Individuals with short pectoralis

70 minor have demonstrated altered scapular kinematics similar to those with subacromial

71 impingement (Borstad & Ludewig, 2005). Recent research has demonstrated a

5
 ACCEPTED MANUSCRIPT

72 negative relationship between pectoralis minor length and scapular dyskinesis based on

73 biomechanical measures (Cools et al., 2014; Forthomme, Crielaard, & Croisier, 2008;

74 Kibler et al., 2013; Kibler & Sciascia, 2010; Ludewig & Reynolds, 2009). However, to

75 date there have been no studies into the influence of pectoralis minor and upper

PT
76 trapezius lengths on scapular dyskinesis determined by visual observation nor have the

77 direction and magnitude of this effect been investigated. Short pectoralis minor and

RI
78 upper trapezius can restrict normal scapular movement, resulting in a more anteriorly

SC
79 tilted, protracted, internally rotated and elevated scapula during arm elevation (Borstad

80 & Ludewig, 2005; Ellenbecker & Cools, 2010; Kibler et al., 2013; Ludewig &

U
81 Reynolds, 2009). This can narrow the subacromial space, leading to shoulder
AN
82 impingement (Borstad & Ludewig, 2005). Short muscles can also be associated with

83 decreased muscle activity of lower stabilizers of the scapula (serratus anterior and lower
M

84 trapezius muscles) (Falla, Farina, & Graven-Nielsen, 2007; Kibler et al., 2013; Kibler,
D

85 Sciascia, & Wilkes, 2012; Manske, Reiman, & Stovak, 2004). Whether the change in

these muscles’ behavior is a contributor to scapular dysfunction or a compensatory

TE

86

87 response to other weakened axioscapular muscles to stabilize the scapula during upper
EP

88 extremity functions is not clear (Borstad, & Ludewig, 2006; Ludewig, & Cook, 2000;

89 Zakharova-Luneva, Jull, Johnston, & O’Leary, 2012).

C

90 Previous authors have indicated that scapular dyskinesis is associated with common
AC

91 shoulder problems such as subacromial impingement or instability (Kibler &

92 McMullen, 2003; Ludewig & Reynolds, 2009; Ludewig & Cook, 2000; Warner,

93 Micheli, Arslanian, Kennedy, & Kennedy, 1992). Therefore, evaluation of the

94 influence of pectoralis minor muscle and upper trapezius muscle lengths on

95 scapular dyskinesis, is warranted in to help us to facilitate possible treatment for

6
 ACCEPTED MANUSCRIPT

96 these subjects. Understanding the direction and magnitude of this effect may facilitate

97 assessment and treatment decision-making for scapular dyskinesis cases (Kibler,

98 Sciascia, & Wilkes, 2012).

99 The aim of this study was to evaluate the influence of pectoralis minor and upper

PT
100 trapezius lengths on visually observable scapular dyskinesis in an asymptomatic

101 population, essentially with investigating the question of to what extent are possible

RI
102 predictors for this case.

SC
103 It was hypothesized that a decrease in pectoralis minor resting length would be

104 associated with an increase in the likelihood of exhibiting scapular dyskinesis and that

U
105 individuals with short upper trapezius would be more likely to exhibit scapular
AN
106 dyskinesis than those with normal trapezius flexibility. Additionally, we hypothesized

107 that arms with positive SDT as compared to those with negative SDT had shorter
M

108 pectoralis minor, and greater incidence of short upper trapezius.

D

109
TE

110

111
EP

112

113
C

114
AC

115

116

117

118

119

7
 ACCEPTED MANUSCRIPT

120 MATERIALS AND METHODS

121 Participants

122 In this cross-sectional study, 148 participants (58 female, 90 male; mean age±SD:

123 23.34±3.94 years; mean body mass index [BMI]±SD:22.93±3.10 kg/m2; 296 arms) were

PT
124 recruited via announcements made in “X” University building during January-July

125 2013. Inclusion criteria: 1. ≥18 years old; 2. did not participate in regular sporting

RI
126 activity, exercise program, or work requiring overhead movements; 3. Turkish-

SC
127 speaking with the ability to understand the nature of the study and provide informed

128 consent; 4. had full range of active shoulder elevation. Participants were not accepted if

129
U
they had medical history of systemic connective tissue, orthopaedic or neurologic
AN
130 disease; pain or limitation in cervical spine range of motion; shoulder pain in the 6

months prior to the study; or history of scapula, clavicle or humerus fracture or surgery.
M

131

132 Participants were also excluded if they had more than 50% range of motion loss in ≥ 2
D

133 planes of shoulder motion, rotator cuff tendinopathy, shoulder instability, full-thickness
TE

134 rotator cuff tear or any other known shoulder pathology (Figure 1).
EP

135 “Insert Figure 1 about here.”

136 After questioning of any known shoulder and/or cervical region problem, one of
C

137 our researchers (a physical therapist with over 10 years of clinical experience in
AC

138 musculoskeletal physical therapy) performed further tests. Pain or limitation in

139 cervical spine range of motion was checked. Rotator cuff disease evaluation was

140 done by impingement tests (Neer’s test, Hawkins–Kennedy test), evaluation of

141 painful arc during active arm elevation, pain or weakness with resisted isometric

142 external rotation, internal rotation or scapular plane abduction with the humeral

8
 ACCEPTED MANUSCRIPT

143 internal rotation (Jobe-Empty can test). Rotator cuff tear was evaluated in case of

144 weakness of the rotator cuff muscles, then drop arm test and lag sign test were

145 used to reveal if the rotator cuff is ruptured or intact. Sulcus Sign at 0 degrees

146 were used to determine multidirectional instability/inferior laxity. Anterior

PT
147 apprehension test were used to test anterior shoulder instability, posterior

148 apprehension for posterior instability. In the case of a positive test the tester

RI
149 proceeded to the relocation test. In the case of a positive test or suspicious results

SC
150 from any of these tests mentioned above, the participant was referred to an

151 orthopaedic surgeon. The orthopaedic surgeon confirmed our results and we

U
152 excluded three participants for rotator cuff tendinopathy and one for shoulder
AN
153 instability.

154 The study was carried out in accordance with the policies and procedures of the
M

155 Declaration of Helsinki, and it was approved by the “X” University Ethics Committee.
D

156 All participants gave written informed consent to participate voluntarily and participant
TE

157 anonymity is preserved.

158 Prior to initiating the study, a power analysis for logistic regression analysis to
EP

159 determine sample size was computed. We considered a model with two predictors and
C

160 as there was no previous study that had similar design to ours we assumed that the event
AC

161 rate under H0 was p1=0.5 and that the event rate under H1 was p2=0.6. The odds ratio

162 (OR) was then OR=1.5. We estimated that the squared multiple correlation between the

163 covariates to be R2=0. A sample size of 208 arms was calculated to be necessary in a

164 two-sided test with α=0.05 and a statistical power of at least 0.80.

165

9
 ACCEPTED MANUSCRIPT

166 Procedures for data collection

167 Participants’ height and weight were measured and recorded. BMI was calculated

168 (BMI=weight (kg)/(height squared (m2)). To ensure blindness and limit bias, different

169 examiners conducted the Scapular Dyskinesis Test and pectoralis minor and upper

PT
170 trapezius length measurements, and the order of the assessments was randomized.

RI
171 Scapular Dyskinesis Test (SDT)

SC
172 SDT is a reliable and valid dynamic assessment method which is visually based and

173 clinically feasible (McClure, Tate, Kareha, Irwin, & Zlupko, 2009; Tate, McClure,

U
174 Kareha, Irwin, & Barbe, 2009, Kibler et al., 2013). Inter-rater reliability of SDT with
AN
175 live rating has moderate to substantial agreement (80-81%) and a weighted kappa

176 ranging from 0.55-0.58 (McClure, Tate, Kareha, Irwin, & Zlupko, 2009), indicating
M

177 relatively higher reliability than other dynamic tests (Kibler et al., 2002; Uhl, Kibler,
D

178 Gecewich, & Tripp, 2009). Our examiner (a physical therapist with over 2 years of
TE

179 clinical experience in musculoskeletal physical therapy and over 1 year of

180 experience in performing SDT) underwent standardized web-based SDT training

EP

181 recommended by McClure et al. (McClure, Tate, Kareha, Irwin, & Zlupko, 2009)

182 (http://www.arcadia.edu/academic/default.aspx?id515080). Intra-rater test–retest

C

183 reliability of this method was calculated from pilot data collected from forty arms and
AC

184 showed nearly perfect agreement: kappa=0.90 (p<0.001), standard error=0.69, 95%CI

185 (0.764, 1.034). In the pilot study, a sub-sample of randomly selected from our

186 participants was assessed for the second time. Random number generator (0-1)

187 was used for randomization to include (1) or exclude (0) the participant to re-test

188 subgroup.

10
 ACCEPTED MANUSCRIPT

189 Males were asked to remove their shirts and females wore halter-tops during the

190 assessment to allow observation of the posterior thorax. The examiner explained and

191 demonstrated the movements for bilateral, active, weighted shoulder a. flexion, and b.

192 abduction (frontal plane) used during the test. Then the participants were instructed to

PT
193 practice each movement. Testing began with participants’ arms at the side of the body,

194 elbows straight, shoulders in neutral rotation, and in thumbs up position; the examiner

RI
195 observed from behind at a distance of two to three meters from the participant.

SC
196 Participants held dumbbells during the tests according to their body weight: 1.4 kg if the

197 participant’s weight was <68.1 kg and 2.3 kg if the participant’s weight was ≥68.1 kg.

198
U
The written operational definitions and rating scale was used to categorize the test
AN
199 results (McClure, Tate, Kareha, Irwin, & Zlupko, 2009). During the SDT, scapular

motion was observed for dysrhythmia and winging over five repetitions of weighted
M

200

201 shoulder flexion and abduction. Dysrhythmia was noted if the scapula demonstrated
D

202 premature, excessive, or stuttering motion during elevation and lowering, or rapid
TE

203 downward rotation during arm lowering. Winging was noted if any portion of the

204 medial border and/or inferior angle of the scapula were posteriorly displaced away from
EP

205 the thorax. According to the results of the SDT either in flexion or abduction, scapular

206 motion was rated as 1. normal if there was no evidence of abnormality; 2. subtle
C

207 abnormality if there was mild or questionable evidence of abnormality occurs and
AC

208 dyskinesis was not consistently present during the trials; or 3. obvious abnormality if

209 there was striking, clearly apparent abnormality, evident on at least 3 of the 5 trials

210 (dysrhythmia or winging of ≥ 2.54 cm displacement of scapula from thorax). Final

211 rating was performed based on combined test movements of flexion and abduction.

212 Final test results were 1. normal - both test motions were rated as normal or one motion

11
 ACCEPTED MANUSCRIPT

213 was rated as normal and the other as having subtle abnormality; 2. Subtle abnormality -

214 both flexion and abduction were rated as having subtle abnormalities; or 3. Obvious

215 abnormality - either flexion or abduction was rated as having obvious abnormality.

216 Tate et al. found a strong correlation between SDT assessments of obvious

PT
217 abnormality and scapular kinematic abnormalities measured by three-dimensional

electromagnetic kinematics analysis (Tate, McClure, Kareha, Irwin, & Barbe, 2009).

RI
218

219 Therefore, the test results were categorized as SDT+ for those classified with obvious

SC
220 dyskinesis and SDT- for those classified as normal or subtle dyskinesis (Figure 2).

U
221 “Insert Figure 2 about here.”
AN
222 Measurement of Pectoralis Minor Resting Length

223 Measurement of the resting length of the pectoralis minor was performed with a cloth
M

224 tape measure using the coracoid process and fourth rib near the sternum as palpable
D

225 landmarks. The validity of these landmarks and reliability of using a cloth tape measure
TE

226 for the measurement have been previously reported (intraclass correlation coefficient

227 [ICC] ranges between 0.82 to 0.86) (Borstad, 2008).3

EP

228 Participants were asked to stand in their normal, relaxed posture, arms resting at the
C

229 side, and look straight ahead during data collection. The fourth rib landmark was
AC

230 palpated at the anterior-inferior edge of the rib, one finger width lateral to the sternum.

231 The examiner initially located the inferomedial aspect of the first rib at the sternum

232 distal to the medial clavicle, then counted down to the fourth rib. The coracoid process

233 landmark was located at its medial-inferior aspect by palpating below the lateral

234 concavity of the clavicle in the deltopectoral groove. Two measurements of the length

235 between the coracoid process and fourth rib landmarks were taken and the average was

12
 ACCEPTED MANUSCRIPT

236 recorded. Pectoralis minor length index (PMI) was used to normalize our measurements

237 to participant’s height to determine the relative length of pectoralis minor. PMI was

238 calculated by dividing the resting length (cm) by subject height (cm), and multiplying

239 by 100 (Borstad, & Ludewig, 2005; Borstad, 2008). Intra-rater test–retest reliability of

PT
240 this method calculated from pilot data collected from forty arms of the aforementioned

241 sub-sample of group revealed excellent reliability (ICC3,2=0.92; SEM90=0.32;

RI
242 MDC90=0.45) (Figure 3).

SC
243 “Insert Figure 3 about here.”

U
244 Upper Trapezius Length Testing AN
245 Testing of upper trapezius length was composed of two parts. First, the participant

246 was seated on a stool without a backrest, feet flat on the floor, neutral trunk posture,
M

247 head straight and facing forward, and arms resting at the side. The examiner stood
D

248 behind the participant, laterally flexed the participant’s neck away from the side being
TE

249 tested, and rotated the head towards the ipsilateral side while controlling the ipsilateral

250 shoulder. Secondly, the examiner lifted the ipsilateral extremity by grasping the forearm
EP

251 under the elbow while the elbow was at approximately 90° flexion and pronated. The

252 test result was positive and recorded as “short” if visually observable further motion of
C

253 the head occurred after lifting the upper extremity, as lifting the arm places the upper
AC

254 trapezius on slack and allows further motion if the trapezius is the cause of limited

255 motion (Manske, Reiman, & Stovak, 2004). Intra-rater test–retest reliability of this

256 method calculated from pilot data collected from forty arms revealed substantial

257 agreement: Kappa=0.72 (p<0.001), Standard error=0.114, 95%CI (0.498, 0.945).

258 (Figure 4)

13
 ACCEPTED MANUSCRIPT

259 “Insert Figure 4 about here.”

260 Data analysis

261 Continuous data were evaluated for normal distribution with the Kolmogorov-

Smirnov test with the Lilliefors Significance Correction. Data are expressed as mean

PT
262

263 values followed by standard deviation or percentages as appropriate. Logistic regression

RI
264 analysis was performed to ascertain the effects of pectoralis minor resting length and

265 upper trapezius length on the likelihood that participants had scapular dyskinesis.

SC
266 Before commencing regression analysis, differences in PMI values in SDT+ and SDT-

U
267 arms were compared using independent t-tests. Chi-square test was used to determine a
AN
268 possible relationship between SDT results and upper trapezius length. Results of these

269 analyses were significant and these predictors were included the model. The software
M

270 package SPSS 20.0 for Windows was used for statistical analysis (IBM SPSS Inc.,

271 Chicago, IL, USA). Statistical significance was set at p <0.05.

D
TE

272

273
EP

274
C

275
AC

276

277

278

279

14
 ACCEPTED MANUSCRIPT

280 RESULTS

281 Among the study participants, scapular dyskinesis was identified in 29.4% (87/296)

282 of the arms and short upper trapezius in 35.5% (105/296) of the arms. Mean PMI in

283 arms with positive SDT was lower compared to those with negative SDT (p <0.05).

PT
284 Upper trapezius shortness was seen more often in arms with scapular dyskinesis than in

285 arms without scapular dyskinesis (p <0.05). Descriptive information for pectoralis

RI
286 minor and upper trapezius lengths of the participants are reported in Table 1.

SC
287 “Insert Table 1 about here.”

U
288 The logistic regression model was statistically significant, χ2=155.747; p<0.001; df=2.
AN
289 The model explained 58.3% (Nagelkerke R2) of the variance in scapular dyskinesis and

290 correctly classified 84.1% of cases. The Wald criterion demonstrated that both PMI and
M

291 upper trapezius length made a significant contribution to prediction (p<0.001 and
D

292 p=0.042, respectively). Increasing PMI was associated with a reduction in the likelihood
TE

293 of exhibiting scapular dyskinesis. For each point increase in PMI, the odds of having

294 scapular dyskinesis decreases 96% (from 1.0 to 0.041). Arms with short upper trapezius
EP

295 were 2.049 times more likely to exhibit scapular dyskinesis than arms with normal

296 upper trapezius length (Table 2).

C

“Insert Table 2 about here.”

AC

297

298

299

300

301

15
 ACCEPTED MANUSCRIPT

302 DISCUSSION

303 Soft tissue shortness is one of the potential contributing mechanisms to abnormal

304 scapular motions (Forthomme, Crielaard, & Croisier, 2008; Ludewig & Reynolds,

305 2009). Our hypothesis was that a decrease in pectoralis minor and upper trapezius

PT
306 lengths would be associated with an increase in the likelihood of exhibiting scapular

307 dyskinesis and our results supported this hypothesis. The shorter the pectoralis minor,

RI
308 the more likely the arm was to have scapular dyskinesis. With each decrease in PMI, the

SC
309 likelihood of having scapular dyskinesis increased by 96%. The likelihood of an

310 individual with short upper trapezius exhibiting scapular dyskinesis was twice that of

U
311 individuals who had normal upper trapezius length.
AN
312 The pectoralis minor, based on its attachments from the medial border of the
M

313 coracoid process to the third through fifth ribs, produces scapular internal rotation,

314 downward rotation, and anterior tilt. It is passively lengthened during the active
D

315 scapular upward rotation, external rotation, and posterior tilting that occurs with arm
TE

316 elevation in healthy individuals (Ludewig, & Cook, 2000). Therefore, excess tension in

317 this muscle could resist these normal scapulothoracic motions (Forthomme, Crielaard,
EP

318 & Croisier, 2008; Phadke, Camargo, & Ludewig, 2009). In this study participants with
C

319 obvious dyskinesis categorized as SDT+ had shorter pectoralis minor resting length
AC

320 compared to those categorized as SDT-. Likewise, Borstad and Ludewig compared

321 short versus long pectoralis minor resting length and assessed scapular motions during

322 arm elevation similar to the nature of the SDT (Borstad & Ludewig, 2005). They found

323 that people with shorter pectoralis minor had significantly less scapular posterior tilt and

324 greater scapular internal rotation during arm elevation. They suggested that compared to

325 a relatively longer muscle, the shortened pectoralis minor demonstrated increased

16
 ACCEPTED MANUSCRIPT

326 passive tension as a result of adaptations such as loss of sarcomeres in series, increased

327 proportions of connective tissue, and loss of passive range of motion. This increase in

328 passive tension as the muscle lengthens during arm elevation might limit motion of the

329 scapulothoracic joint. In contrast, the scapula of individuals with longer pectoralis

PT
330 minor length became further posteriorly tilted at higher arm elevation angles (Borstad &

331 Ludewig, 2005). This can help maintain an open subacromial space, preventing

RI
332 potential soft tissue compression and injury. Similarly, we showed that with each

SC
333 increase in pectoralis minor resting length, the likelihood of having observable scapular

334 dyskinesis decreases 96%. Even though there could be a number of contributing

U
335 factors to abnormal scapular motions, such as decreased activity of the serratus
AN
336 anterior and/or lower trapezius, which are lower stabilizers of the scapula (Falla,

337 Farina, &Graven-Nielsen, 2007; Kibler et al., 2013; Kibler, Sciascia, &Wilkes,
M

338 2012) it is a fair assumption that scapular dyskinesis may be improved or

D

339 prevented through proper interventions to increase muscle length.

TE

340 Another possible reason for the association found between muscle shortness and

341 scapular dyskinesis could be due to decreased activity of the serratus anterior and/or
EP

342 lower trapezius (Falla, Farina, & Graven-Nielsen, 2007; Kibler et al., 2013; Kibler,

343 Sciascia, & Wilkes, 2012). This is speculation of the mechanism according to findings
C

344 in the literature, as muscle strength was not assessed in this study. This speculation is
AC

345 supported by Thigpen et al., who found that individuals with forward head and rounded

346 shoulder posture (FHRSP) display greater scapular internal rotation, anterior tilt and

347 less serratus anterior activity during arm elevation in the sagittal plane and during

348 overhead reaching tasks, likely due to shorter pectoralis minor length (Thigpen et al.,

349 2010). We found that short upper trapezius was seen more in arms with observable

17
 ACCEPTED MANUSCRIPT

350 scapular dyskinesis than in arms without or subtle observable abnormality. Regression

351 analysis revealed that individuals with upper trapezius shortness were 2.049 times more

352 likely to exhibit scapular dyskinesis than people who had normal upper trapezius length.

353 Several alterations in muscle activity and scapular motions have been reported in

PT
354 patients with shoulder impingement, including decreased serratus anterior muscle

355 activation, greater upper trapezius activation, less scapular upward rotation and

RI
356 posterior tilt (Lin et al., 2005; Ludewig & Cook, 2000) and more scapular elevation.

SC
357 There is similarity between these alterations and those found in individuals with short

358 pectoralis minor (Zakharova-Luneva, Jull, Johnston, & O’Leary, 2012). Therefore, the

U
359 effect of short upper trapezius on scapular motions might be two-fold. Upper trapezius
AN
360 shortness: 1. may be related to lesser serratus activation, leading to lesser posterior tilt

361 and upward rotation (Cools et al., 2014; Forthomme, Crielaard, & Croisier, 2008;
M

362 Ludewig & Reynolds, 2009); 2. may increase elevation of the scapula through greater
D

363 clavicular elevation, leading to more anterior tilt (Ludewig & Reynolds, 2009; Phadke,

Camargo, & Ludewig, 2009). Researchers have found lower amounts of serratus
TE

364

365 activation and/or greater upper trapezius activation in different patient populations
EP

366 (sedentary individuals as well as athletes) with shoulder problems (Ludewig & Cook,

367 2000; Lin et al., 2005; Falla, Farina, & Graven-Nielsen, 2007; Phadke, Camargo, &
C

368 Ludewig, 2009). Our findings warrant further study to determine the interaction
AC

369 between these muscle lengths, scapular dyskinesis and scapular muscle activity.

370 Although the literature indicates a possible relationship between shortness of

371 pectoralis minor or upper trapezius and scapular motion alterations (Kibler et al., 2013;

372 Kibler & Sciascia, 2010; Kibler, Sciascia, & Wilkes, 2012; Ludewig & Reynolds, 2009;

373 Manske, Reiman, & Stovak, 2004), few studies have investigated the effect of a short

18
 ACCEPTED MANUSCRIPT

374 pectoralis minor on these alterations and there is no research concerning the role of

375 upper trapezius length. In a study comparing the effects of long versus short pectoralis

376 minor resting length on scapular kinematics, healthy individuals were categorized as

377 having relatively short or long muscle length and their scapular motions were compared

PT
378 using electromagnetic motion capture system. Individuals with a relatively short

379 pectoralis minor resting length demonstrated scapular kinematic patterns similar to

RI
380 patterns seen in shoulder impingement (Borstad & Ludewig, 2005). To the best of our

SC
381 knowledge, the present study is the first to examine the influence of pectoralis minor

382 and upper trapezius length on scapular dyskinesis, and to determine the direction and

U
383 magnitude of this effect using regression analysis. Our analysis showed that having
AN
384 shorter pectoralis minor and upper trapezius length appears to be a very significant risk

385 for having observable scapular dyskinesis. However, it should be kept in mind that
M

386 the Upper Trapezius Length Testing has not been validated previously rather than
D

387 our pilot testing. Since one of our exclusion criteria was “pain or limitation in

cervical spine range of motion”, we can assume that limitation in cervical region
TE

388

389 didn’t play a significant role in results. Additionally, it can be argued that this test
EP

390 in part might also be influenced by other neck rotators likely by the levator

391 scapulae length since both upper trapezius and levator scapulae can be stretched
C

392 with flexion-lateral flexion and rotation. However; upper trapezius is stretched
AC

393 with more lateral flexion while the head is turned towards ipsilateral side whereas

394 levator is stretched with more neck flexion while the head is turned towards the

395 opposite side (Kendall, McCreary, Provance, Rodgers, & Romani, 2005).

396 Scapular motion alterations occur in 68–100% of patients with shoulder injuries

397 (Kibler & McMullen, 2003). Greater scapular internal rotation and anterior tilt during

19
 ACCEPTED MANUSCRIPT

398 arm elevation due to short pectoralis minor length (Borstad & Ludewig, 2005) and

399 scapular elevation resulting from short upper trapezius (Kibler et al., 2013) can narrow

400 the subacromial space, impinge the soft tissues and create an environment leading to

401 pathology/injury (Borstad & Ludewig, 2005). Additionally, the kinetic chain may be

PT
402 interrupted as the unstable scapula aberrantly transmits excessive forces generated from

403 the ground through the lower extremities and torso to the vulnerable shoulder

RI
404 (Forthomme, Crielaard, & Croisier, 2008; Kibler et al., 2013). Determination of the

SC
405 shortness of these muscles as a routine part of the scapular examination seems highly

406 important to avoid scapular dyskinesis and related future shoulder injuries. Future

U
407 studies should follow-up for resultant pathologies.
AN
408 It may be also helpful for treatment decision-making for those with shoulder

problems including visually confirmed scapular dyskinesis. Although this study did not
M

409

410 evaluate changes in scapular dyskinesis after interventions for shortness of the two
D

411 muscles, we speculate that the majority of shoulder pathologies may be improved if
TE

412 scapular dyskinesis and soft tissue shortness can be evaluated and improved. Whether

413 scapular dyskinesis may be altered by proper interventions to increase muscle length is
EP

414 not clear (McClure, Bialker, Neff, Williams, & Karduna, 2004). The usefulness of these

415 methods as a part of the overall treatment program of shoulder dysfunction with
C

416 scapular motion problems and especially the usefulness of these methods alone requires
AC

417 further investigation.

418 Our participants were young, healthy individuals who spent relatively less time with

419 their arms above shoulder level during work, recreation or sports activities.

420 Approximately 30% of all participants had visually confirmed scapular dyskinesis; 36%

20
 ACCEPTED MANUSCRIPT

421 of all participants and 67% of SDT+ participants had short upper trapezius, and SDT+

422 participants had shorter pectoralis minor resting length compared to SDT- participants.

423 However, none of the participants in our study had pain, discomfort or any diagnosed

424 pathology of the shoulder, which may be attributable to young age, demographic,

PT
425 morphologic or chemical factors. In combination with repetitive elevated arm

426 movements, short pectoralis minor length may be a mechanism for shoulder pathology

RI
427 to occur (Borstad & Ludewig, 2005). Therefore, the evaluation of the shortness of these

SC
428 muscles in overhead athletes might be useful for prevention and/or treatment.

429 Limitations

U
AN
430 We categorized participants as SDT+ for those classified as having obvious

431 dyskinesis and SDT- for those classified as being normal or having subtle dyskinesis.
M

432 This determination was based on previous evidence that individuals classified as

433 obvious abnormality in the SDT demonstrated scapular kinematic abnormalities (Tate,
D

434 McClure, Kareha, Irwin, & Barbe, 2009). However, we might have underestimated the
TE

435 effect of having subtle dyskinesis while interpreting the results. Possible reason of

22.5% of upper trapezius shortness seen in SDT- group could be due to this
EP

436

437 limitation. Those participants who have short upper trapezius might have also had
C

438 subtle dyskinesis however we classified them as SDT- according to our

AC

439 predetermined rule for the interpretation of SDT test result. Accordingly,

440 likelihood of exhibiting scapular dyskinesis of people with short upper trapezius

441 might have actually been more then we found in our study.

442 Postural abnormalities were not assessed quantitatively as it has been found that

443 individuals with FHRSP display altered scapular motions likely due to shorter pectoralis

21
 ACCEPTED MANUSCRIPT

444 minor length (Thigpen et al., 2010). Furthermore, scapular muscle activity or strength

445 were not assessed. Determining uncoordinated or insufficient muscle activation,

446 especially in lower stabilizers of the scapula, could have strengthened our arguments on

447 the effects of the inflexibility of these muscles, rather than the mechanisms that we

PT
448 speculated in regard to the literature.

449

RI
450

SC
451

452

453
U
AN
454
M

455

456
D

457
TE

458
EP

459

460
C

461
AC

462

463

464

465

22
 ACCEPTED MANUSCRIPT

466 CONCLUSION

467 It was determined that the shortening of pectoralis minor and upper trapezius lengths

468 increases the likelihood of exhibiting scapular dyskinesis in this asymptomatic

469 population. Having shorter pectoralis minor and upper trapezius appears to be a very

PT
470 significant risk for having observable scapular dyskinesis. Including the assessment of

471 these two muscle lengths as a routine part of the scapular examination may aid

RI
472 treatment decision-making in visually observable scapular dyskinesis. This investigation

SC
473 should be repeated with overhead athletes, who are at risk for impingement, and

474 symptomatic patients who have shoulder injuries, as scapular motion alterations occur

U
475 in almost every case of shoulder injury. Future studies are needed to examine the
AN
476 presence of muscle inflexibility in patients with shoulder pain, and evaluate whether

477 interventions to lengthen these muscles in patients with scapular dyskinesis can improve
M

478 shoulder pain and disability.

D

479
TE

480
EP

481 Funding: We affirm that we have no financial affiliation (including research funding)

482 or involvement with any commercial organization that has a direct financial interest in
C

483 any matter included in this manuscript.

AC

484

485

486

487

23
 ACCEPTED MANUSCRIPT

488 REFERENCES
489 1. Borstad, J.D., & Ludewig, P.M. (2005). The effect of long versus short pectoralis
490 minor resting length on scapular kinematics in healthy individuals. Journal of
491 Orthopaedic & Sports Physical Therapy, 35, 227-238. http://dx.doi.
492 org/10.2519/jospt.2005.35.4.227
493 2. Borstad, J.D., & Ludewig, P.M. (2006). Comparison of three stretches for the

PT
494 pectoralis minor muscle. Journal of Shoulder and Elbow Surgery, 15, 324-330.
495 3. Borstad, J.D. (2008). Measurement of pectoralis minor muscle length: validation

RI
496 and clinical application. Journal of Orthopaedic & Sports Physical Therapy, 38,
497 169-174.

SC
498 4. Cools, A.M., Struyf, F., De Mey, K., Maenhout, A., Castelein, B., & Cagnie, B.
499 (2014). Rehabilitation of scapular dyskinesis: from the office worker to the elite

U
500 overhead athlete. British Journal of Sports Medicine, 48, 692-697.
AN
501 http://dx.doi.org/10.1136/bjsports-2013-092148
502 5. Ellenbecker, T.S., & Cools, A. (2010). Rehabilitation of shoulder impingement
503 syndrome and rotator cuff injuries: an evidence-based review. British Journal of
M

504 Sports Medicine, 44, 319-327.

505 6. Falla, D., Farina, D., & Graven-Nielsen, T. (2007). Experimental muscle pain
D

506 results in reorganization of coordination among trapezius muscle subdivisions

TE

507 during repetitive shoulder flexion. Experimental Brain Research, 178, 385-393.
508 7. Faul, F., Erdfelder, E., Lang, A.G., & Buchner, A. (2007). G*Power 3: a flexible
509 statistical power analysis program for the social, behavioral, and biomedical
EP

510 sciences. Behavior Research Methods, 39, 175-191.

511 8. Forthomme, B., Crielaard, J.M., & Croisier, J.L. (2008). Scapular positioning in
C

512 athlete's shoulder: particularities, clinical measurements and implications. Sports

AC

513 Medicine, 38, 369-86.

514 9. Kendall, F.P., McCreary E.K., Provance P.G., Rodgers M.M., & Romani W.A.
515 (2005). Upper extremity and shoulder girdle. In: Muscles: Testing and
516 Function, with Posture and Pain. (5th ed.) Baltimore, MD: Lippincott,
517 Williams&Wilkins. (pp. 326-331).
518 10. Kibler, W.B., Ludewig, P.M., McClure, P.W., Michener, L.A., Bak, K., & Sciascia
519 A.D. (2013). Clinical implications of scapular dyskinesis in shoulder injury: the

24
 ACCEPTED MANUSCRIPT

520 2013 consensus statement from the 'Scapular Summit'. British Journal of Sports
521 Medicine, 47, 877-885.
522 11. Kibler, W.B., & Sciascia, A. (2010). Current concepts: scapular dyskinesis. British
523 Journal of Sports Medicine, 2010;44:300-305.
524 http://dx.doi.org/10.1136/bjsm.2009.058834
525 12. Kibler, W.B., & McMullen, J. (2003). Scapular dyskinesis and its relation to

PT
526 shoulder pain. Journal of American Academy of Orthopaedic Surgeons, 11, 142-51.
527 13. Kibler, W.B., Sciascia, A., & Wilkes, T. (2012). Scapular dyskinesis and its

RI
528 relation to shoulder injury. Journal of American Academy of Orthopaedic
529 Surgeons, 20, 364-372. http://dx.doi. org/10.5435/JAAOS-20-06-364

SC
530 14. Kibler, W.B., Uhl, T.L., Maddux, J.W., Brooks, P.V., Zeller, B., & McMullen, J.
531 (2002). Qualitative clinical evaluation of scapular dysfunction: a reliability study.

U
532 Journal of Shoulder and Elbow Surgery, 11, 550-556.
AN
533 15. Lin, J.J., Hanten, W.P., Olson, S.L., Roddey, T.S., Soto-quijano, D.A., Lim, H.K.,
534 & Sherwood, A.M. (2005). Functional activity characteristics of individuals with
535 shoulder dysfunctions. Journal of Electromyography and Kinesiology, 15, 576-586.
M

536 16. Ludewig, P.M., & Reynolds, J.F. (2009). The association of scapular kinematics
537 and glenohumeral joint pathologies. Journal of Orthopaedic & Sports Physical
D

538 Therapy, 39, 90-104. http://dx.doi.org/10.2519/jospt.2009.2808

TE

539 17. Ludewig, P.M., & Cook, T.M. (2000). Alterations in shoulder kinematics and
540 associated muscle activity in people with symptoms of shoulder impingement.
541 Physical Therapy, 80, 276-291.
EP

542 18. Lukasiewicz, A.C., McClure, P., Michener, L., Pratt, N., & Sennett, B. (1999).
543 Comparison of 3-dimensional scapular position and orientation between subjects
C

544 with and without shoulder impingement. Journal of Orthopaedic & Sports Physical
AC

545 Therapy, 29, 574-583; discussion 584-586. http://dx.doi.org/10.2519/

546 jospt.1999.29.10.574
547 19. Manske, R.C., Reiman, M.P., & Stovak, M.L. (2004). Nonoperative and operative
548 management of snapping scapula. American Journal of Sports Medicine, 32, 1554-
549 1565.
550 20. McClure, P.W., Bialker, J., Neff, N., Williams, G., & Karduna, A. (2004) Shoulder
551 Function and 3-Dimensional Kinematics in People with Shoulder Impingement

25
 ACCEPTED MANUSCRIPT

552 Syndrome Before and After a 6-Week Exercise Program. Physical Therapy, 84,
553 832-848
554 21. McClure, P.W., Tate, A.R., Kareha, S., Irwin, D., & Zlupko, E. (2009). A clinical
555 method for identifying scapular dyskinesis, part 1: reliability. Journal of Athletic
556 Training, 44, 160-164. http://dx.doi. org/10.4085/1062-6050-44.2.160
557 22. Phadke, V., Camargo, P., & Ludewig P. (2009). Scapular and rotator cuff muscle

PT
558 activity during arm elevation: A review of normal function and alterations with
559 shoulder impingement. Revista Brasileira de Fisioterapia, 13, 1-9.

RI
560 23. Tate, A.R., McClure, P., Kareha, S., Irwin, D., & Barbe, M.F. (2009). A clinical
561 method for identifying scapular dyskinesis, part 2: validity. Journal of Athletic

SC
562 Training, 44, 165-173.
563 24. Thigpen, C.A., Padua, D.A., Michener, L.A., Guskiewicz, K., Giuliani, C., Keener,

U
564 J.D., & Stergiou, N. (2010). Head and shoulder posture affect scapular mechanics
AN
565 and muscle activity in overhead tasks. Journal of Electromyography and
566 Kinesiology, 20(4), 701-709.
567 25. Uhl, T.L., Kibler, W.B., Gecewich, B., & Tripp, B.L. (2009). Evaluation of clinical
M

568 assessment methods for scapular dyskinesis. Arthroscopy, 25, 1240-1248.

569 http://dx.doi.org/10.1016/j.arthro.2009.06.007
D

570 26. Warner, J.J., Micheli, L.J., Arslanian, L.E., Kennedy, J., & Kennedy, R. (1992)
TE

571 Scapulothoracic motion in normal shoulders and shoulders with glenohumeral

572 instability and impingement syndrome. A study using Moire topographic analysis.
573 Clinical Orthopaedics and Related Research, 285, 191-199.
EP

574 27. Zakharova-Luneva, E., Jull, G., Johnston, V., & O’Leary, S. (2012). Altered
575 trapezius muscle behavior in individuals with neck pain and clinical signs of
C

576 scapular dysfunction. Journal of Manipulative and Physiological Therapeutics, 35,

AC

577 346-353. http://dx.doi.org/10.1016/j. jmpt.2012.04.011.

578

579

580

581

26
 ACCEPTED MANUSCRIPT

582 FIGURE CAPTIONS

583
584 Figure 1: Diagram of enrolment and flow chart of study protocol
585

586 Figure 2. A. The scapular motion pattern was classified as '’normal''. B. The scapular
587 motion pattern was classified as ''obvious dyskinesis'' on the left, and “subtle
588 dyskinesis” on the right.

PT
589 Figure 3. Measurement of Pectoralis Minor Resting Length

RI
590 Figure 4. Upper Trapezius Length Testing
591

SC
592 TABLE CAPTIONS

593 Table 1. Pectoralis minor resting length mean±standard deviations and upper trapezius

594 length (n=296 arms).

U
AN
595 Table 2. Logistic regression analysis for variables predicting scapular dyskinesis
M

596 (n=296 arms)

597
D
TE
C EP
AC

27
 ACCEPTED MANUSCRIPT
Table 1. Pectoralis minor resting length mean±standard deviations and upper

trapezius length (n=296 arms).

SDT (+) SDT (–)

Variables p
(n = 87) (n = 209)

PT
PMRL (cm) 12.86 ± 1.04 14.80 ± 1.42 <.001*

RI
PMI 7.49 ± 0.38 8.58 ± 0.75 <.001*

58 Short (66.7%) 47 Short (22.5%)

<.001†

SC
Upper trapezius length
29 Normal (33.3%) 162 Normal (77.5%)
SDT: Scapular dyskinesis test, PMRL: Pectoralis minor resting length,
PMI: Pectoralis minor index

U
* Indicates statistical significance with independent t test comparisons, p<.05
†
Indicates statistical significance with Chi-square test, χ2=52.379, p<.05
AN
M
D
TE
C EP
AC
 ACCEPTED MANUSCRIPT
Table 2. Logistic regression analysis for variables predicting scapular dyskinesis
(n=296 arms)

Variables β S.E. Wald OR 95% CI p

for OR

-3.182 0.447 50.741 0.041 0.017, <.001*

PT
PMI
0.100

Upper trapezius 0.717 0.353 4.124 2.049 1.025, .042*

RI
length 4.094

This model’s correct classification rate=84.1%. Upper trapezius length is a

SC
categorical variable and short muscle was coded as 1.
β: Regression coefficient, S.E.: Standard error, OR: odds ratio, CI: confidence
interval, PMI: Pectoralis minor index

U
* Indicates statistical significance: p<.05
AN
M
D
TE
C EP
AC
 ACCEPTED MANUSCRIPT

Total excluded participant (n=8)

PT
Rotator cuff tendinopathy (n=3)
Shoulder instability (n=1)
Participated overhead sports (n=2)

RI
History of humerus fracture (n=2)

SC
Total recruited (n=148)

U
AN
M
D
TE
EP
C
AC
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC
 ACCEPTED MANUSCRIPT
Highlights

We investigated the influence of muscle length on scapular dyskinesis.

We determined to what extent possible predictors for this case are.

The shorter the pectoralis minor, the more likely the arm has scapular dyskinesis.

PT
Upper trapezius shortness increases the likelihood of exhibiting scapular dyskinesis.

Routine assessment of these muscle lengths in scapular examination is recommended.

RI
U SC
AN
M
D
TE
C EP
AC