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Abstract

Background

Given the limited data regarding three-dimensional clavicular/scapular/humeral rotations of pain-free shoulders in older adults, additional data is required for surgical planning and rehabilitation goal-setting in this population. This observational study aims to provide normative data regarding three-dimensional clavicular/scapular/humeral range required for daily activities in 45–75 year-old individuals.

Methods

Three-dimensional clavicular/scapular/humeral joint ranges were simultaneously recorded using digitization methods. Descriptive statistics were quantified during six functional reaching positions (n = 40 shoulders) for 45–75 year-old participants. Clavicular/scapular/humeral rotations that contributed to the total angle of humeral elevation in flexion, abduction, and during hand-to-head reaching were calculated.

Results

Specific movement patterns were identified in each of the six reaching positions. Normative data for “clavicular elevation:scapular lateral rotation:humeral elevation” ratios were 1°:2°:9° (flexion), 1°:3°:10° (hand-to-head; scapular-plane humeral elevation), and 1°:3°:11° (abduction).

Discussion

Coronal plane clavicular/scapular/humeral rotations contributed to arm elevation height. Transverse plane rotations contributed to positioning the arm toward/away from midline. Sagittal plane clavicular/scapular/humeral rotations contributed to arm positioning in-front/behind the body and subacromial joint alignment. This normative data regarding simultaneous three-dimensional clavicular/scapular/humeral rotations during functional reach enables comparative analysis when evaluating shoulder pain/pathology in older adults.

Keywords

Shoulder biomechanics ROM normative data function activities of daily living

Introduction

Altered alignment and decreased range of motion (ROM) of the clavicle, scapula, and humerus have been associated with shoulder pathology^1–5 and pain^3,4 in both younger and older populations,⁶ and shoulder pain has been shown to correlate with decreased participation in self-care and functional activities.^7–11 ROM and alignment changes have been associated with specific conditions, such as poststroke shoulder pain, subacromial impingement syndrome, adhesive capsulitis, rotator cuff tears, and glenohumeral (GH) instability.^2–5,12,13 Clinical interventions that target shoulder ROM limitations include surgery, joint mobilizations and exercise programs that optimize alignment, improve joint flexibility and improve pain-free functional reach.^3,14 Therefore, establishing baseline three-dimensional (3D) ROM data for the clavicle, scapula and humerus in 45–75 year olds with no known shoulder pain or pathology can provide a valuable reference when evaluating individuals with shoulder conditions,^15,16 and can serve as a benchmark for postsurgical and rehabilitation outcomes.^17–20

When implementing joint mobilizations and exercise programs for shoulder pathologies, clinicians have traditionally referenced Inman et al.'s²¹ classic 1:2 ratio, indicating that for every 1° of coronal plane scapular lateral rotation at the scapulothoracic (ST) joint, 2° of humeral elevation occurs at the GH joint. Although the simplified ratio is easily applicable in the clinical setting, focus on the coronal plane ST:GH ratio alone does not account for the individual contributions of clavicular elevation at the sternoclavicular (SC) joint or scapular lateral rotation at the acromioclavicular (AC) joint.^22–24 Expansion of data sets to include clavicular elevation at the SC joint, scapular lateral rotation at the AC joint, and humeral elevation at the GH joint, which are then combined into SC:AC:GH ROM ratios during functional reach would further enhance our understanding of shoulder girdle reaching patterns. Although recent systematic reviews of motion capture studies have explored 3D rotations at the SC, AC, and GH joints, no studies were found that provided the simultaneous evaluation of all three joints which is required the for the SC:AC:GH ratio.^13,25,26 Additionally, since shoulder ROM has been found to decrease with age,^6,27 investigation of 3D ROM at the SC, AC, and GH joints in ageing individuals is necessary to establish a normative baseline for this group.

The principal goal of shoulder girdle interventions is to increase pain-free shoulder ROM to support engagement in various self-care and daily activities.²⁸ As a result, it is essential to establish normative data for shoulder elevation across varying planes and functional targets. The current study aims to achieve this by building upon previous literature by Gipart et al.²⁴ and Pain et al.²⁹ Gipart et al.²⁴ evaluated the ST:GH ratio using motion capture in the coronal, scapular and sagittal planes in a younger cohort (mean age < 45 years),²⁴ whereas the current study evaluates ST:GH and the SC:AC:GH ratios in the same planes using digitization methods in an older cohort (mean age > 45 years). Additionally, while Pain et al.²⁹ established the reliability of a specific digitization method for assessing these ratios during three reaching positions,²⁹ the present study extends this approach to six functional reaching positions. Evaluation of 3D joint range in various positions is essential since reaching below shoulder height (i.e. below 90° of arm elevation) primarily involves humeral elevation at the GH joint, whereas reaching above shoulder height requires increased ROM contributions from the ST joint via SC and AC joint rotations.^23,29–31 Therefore, evaluating the combined contributions of the SC, AC, and GH joints during specific functional reaching positions above/below shoulder height and toward/away from the body provides clinically relevant insights into functional reaching when engaging in self-care and activities of daily living in the older population.^29–32

The objective of this study was to expand the current data set of 3D clavicular, scapular, and humeral ROM at the SC, AC, and GH joints during rest and six functional reaching positions (3 above and 3 below shoulder height) in 45–75 year-old individuals without a history of shoulder pathology. To build upon the classic coronal plane ST:GH ratio, this expanded data set will also provide coronal plane SC:AC:GH ratios to facilitate application to the clinical setting.

Methods

Participants

This observational study was approved by the University of Toronto Health Sciences Research Ethics Board (REB) (Reference No. 29138). Study participants were recruited over a three-month period using posters and e-mails targeting Toronto and the local community. The inclusion criteria were: (1) 45–75 years of age; (2) no previous rheumatological conditions; (3) no previous orthopedic/neurological conditions of the neck/back/shoulders/upper extremities; (4) ability to reach all tested reaching targets without discomfort/pain; and (5) no pain medication use. To capture normative data on pain-free ROM and function, the study included participants who self-reported no joint pathology or pain. Many individuals experience mild arthritic and postural changes with ageing that do not cause pain or limit functional reaching ability. This study specifically targeted individuals without functional reaching limitations, despite the common occurrence of mild, pain-free arthritic and postural changes with ageing. As a result, additional assessment or diagnostic imaging was not provided to verify the presence of asymptomatic pathology.

Twenty-one participants (n = 42 shoulders) met the inclusion criteria and completed REB-approved informed consent forms; however, only 40 shoulders were digitized as only one shoulder was scanned in two participants due to participant time constraints. Therefore, of the 21 participants (six male/15 female), 19 left and 21 right shoulders were evaluated (n = 40). Participant characteristics are presented in Table 1. Although a prospective sample size calculation based on previous data is the preferred approach, a pre-study sample size calculation could not be performed due to a lack of previous data. Therefore, a retrospective sample size calculation was performed based on pilot data of the average joint ranges required to achieve the humerus-to-thorax angle of 130° during sagittal plane flexion. A sample size of 38 shoulders was determined based on the following: ((Z_1−a/2)²(SD)²/d²; where Z = 1.96; SD = 10°; d = 10°).³³

Table 1.

Subject characteristics.

	Total Sample	Subgroups
	Age 45–75	Age 45–< 55	Age 55–< 65	Age 65–75
Study participants: n = 21 Males:females	6:15	3:4	1:6	2:5
Age (yrs): Mean (SD) Range	58.6 (10.6) 45.0–74.0	47 (1.9) 45–51	58.3 (2.9) 55–64	72.5 (2.3) 68–75
Height (cm): Mean (SD) Range	168.4 (10.9) 152.4–188.0	172.0 (12.6) 152.4–185.4	168.4 (10.3) 154.9–188.0	164.3 (8.3) 154.9–177.8
Weight (kg): Mean (SD) Range	62.8 (10.7) 48.1–84.8	64.6 (14.8) 48.1–84.8	60.7 (5.5) 52.6–70.3	63.2 (9.9) 53.5–81.6
Sample size: n = 40 Shoulders Shoulder (R:L)	40 (21:19)	14 (7:7)	14 (7:7)	12 (7:5)

Note. R/L, right/left; SD, standard deviation; yrs, age in years; cm, height in cm; kg, weight in kg.

Study protocol

Three-dimensional rotations of the clavicle, scapula and humerus were investigated at the SC, AC and GH joints bilaterally in each participant at rest, and while performing six functional reaching tasks. Participants were seated with the pelvis in neutral using a lumbar support, the hip and knee joints in 90° of flexion, and feet flat on the floor with ankles at 90°. A seatbelt was used to stabilize the participant's back against the chair and to limit thoracic rotation.

The right and left upper limbs of each participant were tested at rest, and in six reaching positions. Specific test positions were selected to examine functional reaching above/below shoulder height and toward/away from the body. At rest, the humerus was aligned vertically against the thorax, and the hand was placed in pronation on the ipsilateral thigh. The six reaching positions included: (1) 130° of humeral flexion in the sagittal plane (elbow fully extended; forearm in midprone position); (2) 130° of humeral abduction in the coronal plane (elbow fully extended; forearm in midprone position); (3) 60° of humeral external rotation in the transverse plane (humerus parallel to the thorax; 90° of elbow flexion; forearm in midprone position); (4) hand-to-head with humeral elevation in the scapular plane (elbow fully flexed; metacarpal–phalangeal joint of the third digit placed on head in the mid-coronal plane); (5) hand-to-shoulder (tip of the third digit placed on the opposite shoulder over the center of the acromion; humerus/forearm resting against the body); (6) hand-behind-back (dorsal surface of metacarpal-phalangeal joint of the third digit placed over the midpoint of the superior border of the sacrum).

A goniometer was used to position the participants in 130° of sagittal plan flexion and coronal plane abduction, and 60° of external rotation. Once positioned, the participants actively grasped a stationary pole to maintain static positioning during testing. For hand-to-head, hand-to-shoulder and hand-behind-back reaching, the hand was stabilized against the head, shoulder and back respectively. To prevent extraneous movement in all positions, a research assistant physically stabilized and monitored the participants. If movement occurred, the participant was repositioned and reevaluated.

The positions of flexion and abduction to 130° and external rotation to 60° were standardized using goniometry. During flexion and abduction testing, the goniometer's axis of rotation was placed 1 in. below the acromion, with the stationary arm parallel to the trunk and the moving arm parallel to the humerus shaft. Goniometry was used to position the shoulder as this method is clinically reproducible. However, the goniometric axis inevitably differs from the one described by the International Society of Biomechanics (ISB) for motion capture and digitization methods.³⁴ For digitization, the shoulder's x-axis of rotation is based on a line perpendicular to the plane formed by points on the lateral epicondyle, medial epicondyle, and the GH rotation center. Consequently, variations will exist between goniometric and digitization angles.

The 3D ROM of the clavicle, scapula and humerus was determined using the palpation/digitization method, which was developed based on bony landmarks recommended by the ISB.³⁴ Ten bony landmarks were palpated and digitized by an experienced physiotherapist using a MicroScribe MX Digitizer (accuracy up to 0.002 inches (0.0508 mm)).³⁵ This digitization tool collects Cartesian coordinate data of individual digitized points while the study participant maintains a static position. The Cartesian coordinate data is then used to reconstruct joint and segment rotations of the clavicle, scapula and humerus in 3D space between the study participant's initial static resting position to a subsequent static test position. The ISB protocol allows for the identification of only two bony landmarks on the clavicle through noninvasive palpation.³⁴ However, without a third point, the axial rotation of the clavicle can only be estimated using optimization techniques.³⁴ As a result, this study evaluated clavicular elevation/depression and protraction/retraction but excluded clavicular axial rotation.

In addition to providing specific bony landmarks, the ISB also provided a protocol for defining joint coordinate systems when examining three-dimensional motion of the clavicle, scapula and humerus.³⁴ A modified version of the 2005 ISB protocol was developed by Pain et al. (2019) for use in individuals with and without alterations in joint alignment and pain.²⁹ To assess this population, the following three modifications were made to the original ISB protocol³⁴:

To reduce assessment time and subject fatigue, the number of digitized points was reduced by excluding the xiphoid process.²⁹

The adapted protocol employed an updated rotation sequence to calculate humeral 3D rotations when the humerus is positioned in less than 60° elevation.^36,37

An updated modified regression method was obtained from the International Shoulder Group website³⁸ and was used to optimize the estimates for the GH center of rotation.^34,39,40

Using this modified version of the 2005 ISB protocol, a reliability study was conducted to determine the intraclass correlation coefficients (ICCs) and the standard error of the mean (SEM) for the positions of rest, flexion, abduction, and external rotation.²⁹ This protocol demonstrated high to very high test–retest reliability (ICC > 0.70) and repeatability (SEM of ≤3.75° for all joints, except humeral axial rotation with an SEM of ≤5°) in a fully powered sample of asymptomatic participants.²⁹ Using this adapted protocol, the following landmarks were palpated and digitized in the current study: spinous processes of the seventh cervical and eighth thoracic vertebrae; suprasternal notch; AC joint; coracoid process; angle of acromion; root of the spine and inferior angle of the scapula; and lateral and medial epicondyles of the humerus. After all the 10 points were digitized, the joint coordinate system was developed using the sternal notch, C7, and T8.

Following digitization, data from the rest and six reaching positions were imported into Autodesk Maya software. Bone rotations were computed in specific planes as the clavicle-to-thorax angle at the SC joint, scapula-to-clavicle at the AC joint, and humerus-to-scapula at the GH joint. The terminology used for rotations of the clavicle (in two planes), the scapula (in three planes), and the humerus (in three planes) is consistent with the ISB terminology,³⁴ and are listed below:

Clavicle: (1) elevation/depression (coronal plane); (2) protraction/retraction (transverse plane)

Scapula: (1) medial/lateral rotation (coronal plane); (2) protraction/retraction (transverse plane); (3) anterior/posterior tilt (sagittal plane)

Humerus: (1) horizontal adduction/abduction (transverse plane); (2) internal/external rotation along the longitudinal axis; (3) elevation.

Next, segmental rotations of the scapula and humerus relative to the thorax were computed for the three scapular and three humeral rotations listed above. The rotations of the scapula (in three planes), and the humerus (in three planes) are listed below:

Scapula: (1) medial/lateral rotation (coronal plane); (2) protraction/retraction (transverse plane); (3) anterior/posterior tilt (sagittal plane).

Humerus: (1) horizontal adduction/abduction (transverse plane); (2) internal/external rotation along the longitudinal axis; (3) elevation.

Data analysis

IBM SPSS Statistics software (Version 25) was used for statistical analysis. Participant characteristics, including age, sex, height, and weight, were summarized using descriptive statistics (mean ± SD, range).

A mean rotation angle of three measurements for each joint and segment rotation was calculated. The mean angle for each of the eight joint rotations and six segment rotations in the rest position was subtracted from the corresponding mean angle in the test positions to obtain the total ROM. The ROM data was used to compute the mean and SEM for each of the eight joint rotations and six segment rotations in all six reaching positions. To examine the influence of outlier data, the mean and standard deviation of the participants in the 10th to 90th percentile of the joint/segment ROM data were also computed. Finally, to facilitate comparisons between Inman et al.'s²¹ classic ST:GH ratio of 1:2 to the current study results, both the ST:GH ratio and the SC:AC:GH ratio for humeral elevation in the coronal plane were calculated in rounded values.

Results

Forty shoulders (21 right/19 left) were evaluated in 21 participants (6 male/15 female). All participants were tested bilaterally, except for two where only the right shoulder was tested due to the participants’ time constraints (Figure 1). Participant characteristics are presented in Table 1.

Figure 1.

Sample size flow chart.

Normative baseline data regarding 3D rotations of the clavicle, scapula and humerus at the SC, AC, and GH joints during rest and six functional reaching positions (three above and three below shoulder height) was quantified. The mean (SEM) ROM for each joint/segment rotation for the full sample (n = 40) in all reaching positions was summarized in Figure 2 and to 1 decimal point in the Supplemental Table. The mean (SD) rotation angles in each joint/segment for the 10th to 90th percentile of the study sample during each test movement is provided to 1 decimal point in Table 2. The SC:AC:GH joint ROM ratio for humeral elevation in the coronal plane was also constructed, however it was discussed in whole numbers to facilitate comparisons with Inman et al.'s²¹ classic 1:2 ST:GH ratio and presented in Figure 3. Bone rotation patterns were identified for each functional reaching position, and functional reaching positions were explored within the context of reaching above and below shoulder height.

Figure 2.

Mean (SEM) range of motion at each joint/segment for each test movement (N = 40). Note: R, retraction; P, protraction; E, elevation; D, depression; LR, lateral rotation; MR, medial rotation; PT, posterior tilt; AT, anterior tilt; PL, initial plane of elevation at rest; HAd, horizontal adduction; HAb, horizontal abduction; ER, external rotation; IR, internal rotation; SC(Clav), clavicular rotation at sternoclavicular joint; AC(Scap), scapular rotation at acromioclavicular joint; GH(Hum), humeral rotation at the glenohumeral joint; Scap/Thorax, scapular rotation relative to thorax; Hum/Thorax, humeral rotation relative to thorax; ROM, range of motion. SEM, standard error of the mean.

Figure 3.

Ratios* of clavicular elevation to scapular lateral rotation to humeral elevation (in degrees) compared to the total humerus-to-thorax elevation ROM during overhead reaching. Note: SC + AC + GH, ratio of clavicular elevation at sternoclavicular joint to scapular lateral rotation at acromioclavicular joint to glenohumeral elevation at glenohumeral joint; Hum/Thorax, angle of humerus elevation relative to the thorax; Flex, sagittal plane flexion; HTH, hand-to-head with humerus elevated in scapular plane; Abd, coronal plane abduction; GH-Hum EL, humeral elevation at glenohumeral joint; AC-Scap LR, scapular lateral rotation at acromioclavicular joint; SC-Clav EL, clavicular elevation at sternoclavicular joint; Hum/Thorax EL, humeral elevation angle relative to thorax; ROM, range of motion. *Ratios: Flex = 1:2:9; HTH = 1:3:10; Abd = 1:3:11.

Table 2.

Mean (SD) range of motion (degrees) for the 10th to 90th percentile (n = 32) at each joint/segment for each test movement.

	Sternoclavicular joint		Acromioclavicular joint			Glenohumeral joint			Scapula relative to thorax			Humerus relative to thorax
	Pr/Rt	D/EL	Pr/Rt	MR/LR	PT/AT	HAd/HAb	D/EL	IR/ER	Pr/Rt	MR/LR	PT/AT	HAd/HAb	D/EL	IR/ER
Rest*	15.8 (4.3)	3.5 (2.7)	44.9 (3.3)	4.5 (3.5)	3.6 (2.7)	5.2 (3.5)	11.1 (3.9)	6.2 (6.1)	29.2 (3.9)	6.8 (2.7)	1.3 (2.7)	50.6 (12.8)	19.3 (3.0)	25.7 (13.2)
	Rt	EL	Pr	LR	PT	PL	EL	ER	Pr	LR	PT	PL	EL	ER
Flex	10.6 (5.2)	9.8 (3.2)	4.9 (3.0)	19.2 (4.3)	18.8 (5.8)	3.3 (19.3)	91.6 (6.2)	39.9 (19.8)	0.1 (4.3)	24.4 (5.7)	9.4 (3.9)	10.5 (14.8)	116.7 (6.0)	36.2 (17.8)
	Rt	EL	Pr	LR	PT	HAd	EL	ER	Rt	LR	PT	HAd	EL	ER
Abd	20.5 (4.1)	7.4 (2.9)	1.2 (3.7)	24.1 (4.4)	25.1 (5.4)	24.4 (19.2)	79.6 (6.0)	35.3 (18.0)	14.2 (3.9)	29.0 (5.6)	17.5 (3.7)	39.1 (14.9)	106.5 (6.0)	60.6 (14.9)
	Rt	EL	Pr	LR	PT	HAb	EL	ER	Rt	LR	PT	HAb	EL	ER
HTH	17.4 (2.9)	8.3 (3.1)	5.9 (4.1)	21.2 (4.7)	18.7 (5.0)	3.6 (19.8)	82.9 (7.0)	43.6 (18.6)	6.2 (4.5)	25.8 (6.1)	10.3 (3.8)	5.0 (14.6)	109.3 (9.1)	40.3 (16.0)
	Rt	EL	Pr	LR	PT	HAd	EL	ER	Rt	LR	PT	HAd	EL	ER
ER	1.2 (2.5)	0.7 (1.8)	1.3 (2.8)	3.9 (3.9)	1.6 (2.2)	3.3 (5.1)	0.4 (3.8)	51.5 (7.5)	2.8 (3.2)	3.4 (3.8)	2.1 (2.4)	3.9 (10.7)	1.7 (3.1)	57.3 (15.3)
	Rt	EL	Rt	MR	AT	HAd	EL	ER	Rt	MR	AT	HAd	EL	ER
HTS	2.7 (5.4)	6.8 (2.1)	7.2 (3.0)	10.6 (4.8)	11.6 (4.1)	40.3 (6.1)	5.9 (6.8)	49.8 (10.0)	7.3 (5.7)	14.4 (5.3)	5.5 (3.3)	57.5 (14.8)	38.3 (4.1)	10.3 (16.3)
	Rt	EL	Pr	LR	PT	HAd	EL	IR	Pr	LR	PT	HAd	EL	IR
HBB	1.0 (2.4)	2.3 (2.3)	0.7 (2.6)	3.9 (3.7)	3.3 (2.7)	19.4 (6.4)	6.0 (5.3)	69.6 (7.9)	0.2 (3.4)	2.4 (3.0)	4.7 (2.5)	60.3 (13.3)	10.0 (6.1)	126.5 (13.4)
	Pr	EL	Pr	MR	AT	HAb	EL	IR	Pr	MR	AT	HAb	EL	IR

Note: Flex, flexion; Abd, coronal plane abduction; HTH, hand to head; ER, external rotation; HTS, hand to shoulder; HBB, hand behind back; Pr/Rt, protraction/retraction; D/EL, depression/elevation; MR/LR, medial rotation/lateral rotation; PT/AT, posterior tilt/anterior tilt; PL, plane of elevation at rest; HAd/HAb, horizontal adduction/abduction; IR/ER, internal rotation/external rotation. *Rest values are relative to the thoracic coordinate system; all other values (Flex, Abd, ER, HTH, HTS, and HBB) are relative to the rest position.

Functional reach above shoulder height

Multidimensional rotations occurred at the SC, AC, and GH joints to position the upper extremity for reach above shoulder height, when moving from the initial resting position to sagittal plane flexion, coronal plane abduction and hand-to-head reaching with the humerus in the scapular plane (Figure 2; Supplemental Table). ROM results and the SC:AC:GH joint ROM ratio for humeral elevation in the coronal plane (Figure 3) are summarized for each position below. For each of these positions, the humerus is evaluated relative to the scapula at the GH joint, the scapula relative to the clavicle at the AC joint, and the clavicle relative to the thorax at the SC joint:

Sagittal plane flexion to 130°

Coronal plane: The sum of the mean joint rotations (clavicular elevation, 10.0° [±0.7°]; scapular lateral rotation, 19.2° [±1.0°]; and humeral elevation, 91.4° [±1.5°]) approximated the mean total humerus-to-thorax elevation angle of 117.3° (±1.3°) (Figure 2; Supplemental Table). Thus, the SC:AC:GH ROM ratio was 1°:2°:9° (Figure 3).

Transverse plane: Joint rotations included clavicular retraction (10.9° ± 1.1°), scapular protraction (5.1° ± 0.7°), and humeral horizontal adduction (7.0° ± 5.9°).

Sagittal plane: Rotations included scapular posterior tilt (19.1° ± 1.3°) and humeral external rotation (44.0° ± 6.8°).

Coronal plane abduction to 130°

Coronal plane: The sum of the mean joint rotations (clavicular elevation, 7.6° [±0.7°]; scapular lateral rotation, 24.0° [±1.0°]; humeral elevation, 79.8° [±1.3°]) approximated the mean total humerus-to-thorax elevation angle of 106.8° (±1.4), with an SC:AC:GH ROM ratio of 1°:3°:11° (Figure 3, Supplemental Table).

Transverse plane: Joint rotations included clavicular retraction (20.5° ± 0.9°), scapular protraction (1.1° ± 0.9°) and humeral horizontal abduction (21.7° ± 6.2°).

Sagittal plane: Rotations included scapular posterior tilt (24.6° ± 1.2°) and humeral external rotation (39.8° ± 6.2°).

Hand-to-head reaching

Coronal plane: The sum of the mean joint rotations (clavicular elevation, 8.5° [±0.7°]; scapular lateral rotation, 21.4° [±1.1°]; humeral elevation, 81.8° [±1.7°]) approximated the mean total humerus-to-thorax elevation angle of 109.2° ± 1.8°, with an SC:AC:GH ROM ratio of 1°:3°:10° (Figure 3, Supplemental Table).

Transverse plane: Joint rotations included clavicular retraction (17.5° ± 0.7°), scapular protraction (5.9° ± 0.9°), and humeral horizontal adduction (6.9° ± 6.2°).

Sagittal plane: Rotations included scapular posterior tilt (19.1° ± 1.1°) and humeral external rotation (47.5° ± 6.4°).

Functional reach below shoulder height

When moving from the resting position to the three reaching positions below shoulder height, the majority of the ROM occurred at the humerus, with small ROM changes at the SC and AC joints (Figure 2; Supplemental Table).

External rotation to 60°

Sagittal plane: The primary movement was humeral external rotation (GH joint: 51.0° ± 1.9°; humerus-to-thorax: 58.5° ± 3.9°), with < 2° anterior tilt of the scapula.

Coronal and transverse planes: All joint rotations were <4°.

Hand-to-shoulder reaching

Sagittal plane: The primary movement was internal rotation at the GH joint (48.8° ± 2.3°) with 11.9° ± 0.9° of scapular protraction.

Coronal plane: Rotations included 6.4° ± 0.8° of clavicular elevation, 11.2° ± 1.3° of scapular lateral rotation and 5.9° ± 1.4° of humeral elevation.

Transverse plane: The primary movement was humeral horizontal adduction at the GH joint (39.9° ± 1.3°) with a small amount of clavicular retraction (<4°) and scapular protraction (<8°).

Hand-behind-back reaching

Sagittal plane: The primary movement was internal rotation at the GH joint (68.4° ± 2.2°), with <4° of scapular anterior tilt.

Coronal plane: Rotations included clavicular elevation (<2°), scapular medial rotation (<4°), and humeral elevation (<6°).

Transverse plane: The primary movement was humeral horizontal abduction at 19.5° ± 1.3°. Clavicular and scapular protraction was <2°.

Discussion

The ability to engage in functional reaching is a clinically relevant goal. This study aimed to establish normative baseline data for 3D rotations of the clavicle, scapula, and humerus at the SC, AC, and GH joints during rest and six functional reaching positions (three above and three below shoulder height) in 45–75 year-old individuals. Methodological differences (i.e. variations in testing positions, and use of digitization to measure static ROM versus use of motion capture to measure dynamic ROM) precluded direct comparison between the ROM data obtained from this study with other studies. Where direct comparisons of numerical ROM data could not be made with other studies, observations regarding the direction of movement were explored. Additionally, the current study evaluated clavicular and scapular data separately to determine SC:AC:GH ratios, and jointly to determine ST:GH ratios. Since SC:AC:GH ratios were not found in any other studies, only comparisons between ST:GH ratios were made.

The six test positions included functional reaches towards/away from the body, as well as reaches above/below shoulder height. Functional reach toward the body (i.e. hand-to-head, hand-to-opposite shoulder, and hand-behind-back) is essential for self-care (i.e. feeding, dressing, grooming, and hygiene).^31,32 Functional reach away from the body (i.e. sagittal plane flexion, coronal plane abduction, and external rotation) is essential for allowing an individual to interact with their environment.^31,32 While functional reach toward and away from the body are clinically relevant, the current study identified that reaching below shoulder height primarily involves humeral elevation at the GH joint, whereas reaching above shoulder height requires increased ROM contributions from clavicular and scapular rotations (i.e. the ST joint). Clavicular/scapular/humeral ROM was calculated for each joint within the coronal plane, the transverse plane and the sagittal plane, and similar to other studies,^23,31,32 common rotation patterns were seen when reaching above shoulder height versus below shoulder height.

Functional reach above shoulder height

During coronal plane abduction, the ST:GH ratio of 1°:2° is traditionally used to describe the relative amount of scapular lateral rotation at the ST joint to humeral elevation at the GH joint.²¹ Subsequent studies have reported variations in ST:GH ratios at different heights of limb elevation in the coronal plane,²² the sagittal plane,²³ and during limb elevation versus limb lowering in subjects aged 18–60.²³ In 2013, Giphart et al.²⁴ reported ST:GH ratios in different planes of elevation in a younger cohort (mean age 29 ± 6 years) using motion capture methods. Their findings included a ratio of 1°:2.0° ± 0.4° for coronal plane abduction, 1°:1.6° ± 0.5° for scapular plane elevation, and 1°:1.1° ± 0.3° for sagittal plane flexion—approximating whole number ratios of 1°:2°, 1°:2°, and 1°:1°, respectively. In contrast, the current study used digitization methods in an older cohort (59 ± 11 years) and similarly observed plane-specific variations in ST:GH ratios with 1°:2.8° for 130° of coronal plane abduction, 1°:3.2° for hand-to-head reaching with humeral elevation in the scapular plane, and 1°:3.7° for 130° of sagittal plane flexion, approximating whole number ratios of 1°:3°, 1°:3° and 1°:4° respectively. The observed variations between study findings may reflect differences in study methodologies, measurement techniques, limb elevation height, or participant demographics between cohorts. However, further research is needed to clarify the effect of these factors. Similar to the slight variations in ST:GH ratios found during different planes of limb elevation,²⁴ the individual joint contributions to the SC:AC:GH ratio also demonstrated small variations between sagittal plane flexion (1°:2°:9°), scapular plane humeral elevation during hand-to-head reaching (1°:3°:10°), and coronal plane abduction (1°:3°:11°). Compared to the ST:GH ratio,^22–24 the SC:AC:GH ratio provides a more comprehensive assessment of individual shoulder joint ranges, as the separate contributions from each of the three joints are accounted for.

While scapular and humeral rotations have been widely cited in the literature as contributors to limb elevation,^4,6,21,24,41 the contribution of the clavicle also requires further study.⁴¹ Previous studies have evaluated clavicular ROM in individuals without any known pathology.^42–44 However, these studies either assessed clavicular ROM in isolation⁴² or examined clavicular and scapular ROM without the humerus.⁴⁴ Additionally, these studies used motion capture systems to evaluate participants with a mean age younger than 30 years.^42–44 In contrast, the current study evaluated an older cohort of individuals with a mean age of 58.6 years and used digitization methods to simultaneously evaluate the 3D rotations of the clavicle, scapula, and humerus to determine the SC:AC:GH ratio in different planes of humeral elevation. As a result, this data provides novel contributions to clinical practice by highlighting the combined contributions of all three shoulder bones during various functional reaching positions.

When examining coronal plane humeral elevation, comparison between the individual SC:AC:GH angles to the total humerus-to-thorax angle provided some noteworthy findings. The total humerus-to-thorax elevation angle (117.3° (SD ± 1.3)) approximated the sum of the separate coronal plane angles of clavicular elevation at SC (10.0° (SD ± 0.7°)), scapular lateral rotation at AC (19.2° (SD ± 1.0°)), and humeral elevation at the GH joint (91.4° ( ± 1.5°)) (sum of 3 angles = 120.6°). Therefore, clavicular elevation, scapular lateral rotation and humeral elevation appear to be primary joint rotations contributing to the height of limb elevation. While the total humerus-to-trunk angle and the sum of the individual joint angles are very similar, the slight variation in angles may be attributed to potential sources of measurement error. Previous intrarater test–retest reliability and within-subject repeatability of the palpation and digitization approach demonstrated high to very high intrarater test–retest measurement reliability in asymptomatic shoulders during coronal plane abduction, with a standard error of measure of < 3.5°.²⁹ This standard error of measurement may account for the 3.3° difference between the total humerus-to-thorax angle and the sum of the separate SC, AC, and GH joint angles found in the current study. Conversely, minor additional joint rotations in the trunk may also make subtle contributions to limb elevation, despite being stabilized during the measurement process.

In the transverse plane, our results indicated that protraction/retraction of the clavicle and scapula at the SC and AC joints respectively, as well as humeral horizontal adduction/abduction at the GH joint all contributed to the total range of horizontal adduction/abduction of the arm as it moved toward/away from midline. Although these joint rotations contribute to the total humerus-to-thorax angle in the transverse plane, no previous studies have been found that reported all three joint rotations simultaneously. Previous studies evaluating separate joint rotations as the humerus moved laterally from sagittal plane flexion to coronal plane abduction, identified a trend of progressive clavicular retraction,^42–44 scapular retraction,^45,46 and GH horizontal abduction.⁴⁶ Compared to these previous studies that used motion capture technology in younger age groups (mean age ≤ 40 years old),^42–46 the current study found similar joint rotation patterns using digitization methods in older groups.²⁹ Although the digitization method evaluates the limb in a static position, this method enables evaluation of all three shoulder girdle joints simultaneously, and provides a more comprehensive overview of the individual joint contributions during a specific reaching position.

In the sagittal plane, the results of the current study suggest that scapular anterior/posterior tilt at the AC joint, and axial rotation of the humerus at the GH joint, not only contributed to anterior/posterior reach in front/behind the body, but these rotations also maintain alignment of the GH joint. As noted in previous studies, scapular posterior tilt increases the amount of space between the acromion and the humeral head during arm elevation, and external rotation of the humeral head rotates the greater tubercle away from the acromion, thus helping to prevent impingement when reaching overhead.^3,47,48 An understanding of the joint rotations that maintain the subacromial space is an essential component of surgical and rehabilitation treatment interventions aimed at treating subacromial impingement syndromes.^3,49,50 Finally, clavicular axial rotation in the sagittal plane may also play a role in positioning the hand in front/behind the body and GH alignment. As a result, it is anticipated that future studies will add additional insights into the specific contributions of this rotation.

Functional reach below shoulder height

When reaching below shoulder height, the current study results suggest that the majority of ROM occurs in axial rotation at the GH joint. Unlike previous studies that used motion capture technology to evaluate the end ROM during dynamic movements (such as reaching to the opposite shoulder or behind the back),^51–53 this study specifically assessed ROM between two static positions. Interestingly, the results from those dynamic movement studies^51–53 were similar to the findings in this study, as the primary rotations required were humeral internal/external rotation at the GH joint along with minimal rotations at the ST joint. Although the methodological differences between studies (e.g. variations in coordinate systems, Euler rotation sequences, and estimation of GH center of rotation) make direct comparison of ST and GH angles challenging, the direction of joint rotations were consistent across studies.^51–53 In addition to evaluating the ST and GH angles, the current study also simultaneously evaluated the individual joint rotations of the SC and AC when reaching into external rotation (with the humerus parallel to the thorax), reaching to the opposite shoulder and reaching behind the back. This data more clearly demonstrates the limited contributions of the SC and AC joint ROM in these positions, and suggests that surgical and rehabilitation treatment interventions aiming to improve functional reach below shoulder height should be targeted more toward GH IR, and ER, instead of clavicular and scapular ROM.

The goal of the current study was to accurately capture the 3D end-range ROM of the clavicle, scapula, and humerus during various functional reaching positions. Participants self-reported no known shoulder pathology and were able to reach all testing targets with no reports of discomfort or pain. As with any age group, confounding variables such as participants’ activity levels and underlying postural conditions (e.g. developing kyphosis)^54–57 may influence muscle and joint flexibility,^58,59 and impact ROM data. That being said, the current study group aimed to be reflective of the typical ROM found within older population of individuals with no known shoulder pain or functional limitations. Also, the current study employed static digitization methods as opposed to motion capture methods. While motion capture systems can evaluate kinematic and ROM data between two testing positions, the skin-mounted markers and inertial sensors used by these systems may not map directly with the underlying 3D rotations of the bones, particularly at higher elevations.^60–62 As a result, anatomical landmark palpation and static digitization methods have been suggested for 3D scapular evaluation at these higher ranges.^60–62 Although more time-consuming, this method potentially offered more accuracy.²⁹

Although the palpation/digitization method previously demonstrated high to very high test–retest reliability and repeatability,²⁹ the current study results were limited due to sample size considerations. The limited cohort size prevented stratification by age, sex, or limb dominance, which would lead to an underpowered subgroup analysis. Also, evaluating both shoulders per participant also introduces potential within-subject correlation, which may affect generalizability. Finally, given the limited testing tolerance of the participants, only end-range positions were evaluated. Additional studies evaluating mid-range positions (ideally combining motion capture and digitization methods) would provide a more comprehensive picture of functional shoulder range and movement. Despite this, the current study data can contribute to the development of a larger normative database regarding pain-free shoulder ROM in 45+ year-old adults. Future studies with larger sample sizes will enable further investigation of these variables, and stratified subgroup analysis.

The normative ROM data from the current study have potential applications in goal setting for surgical planning,^17–20,63 mobilizations,^64,65 and exercise protocols.^66,67 Since the three bones of the shoulder girdle move collaboratively, introducing the SC:AC:GH ratios and maximum ROM required for various functional reaching positions toward and away from the body can contribute to the growing body of research regarding assessment and interventions for shoulder pathology.^{9,11,26–28,30–32}

Conclusions

This study provides normative 3D ROM data for the clavicle, scapula, and humerus during rest and six functional reaching positions in individuals aged 45–75, which provides a standard of comparison for individuals experiencing shoulder pain and pathology. The novel use of the SC:AC:GH ratio quantifies the distinct contributions of clavicular elevation at the SC joint, scapular lateral rotation at the AC joint, and humeral elevation at the GH joint, which were not fully captured by the previously documented ST:GH ratios. Finally, this study identified specific patterns of clavicular/scapular/humeral rotations in different planes of movement. All three rotations in the coronal plane contributed to the height of limb elevation. All three rotations in the transverse plane contribute to horizontal reaching toward/away from the midline, and rotations in the sagittal plane contribute to functional reach in front/behind the body and may contribute to subacromial alignment. Overall, these novel contributions pertaining to shoulder joint rotation patterns in this older cohort can guide surgical and rehabilitation interventions that restore complex reaching abilities, aiding in the recovery of independent self-care and the ability to interact with one's environment.

Supplemental Material

sj-docx-1-sel-10.1177_17585732251352452 - Supplemental material for Three-dimensional range of motion of the clavicle, scapula, and humerus during functional reach in adults aged 45–75

Supplemental material, sj-docx-1-sel-10.1177_17585732251352452 for Three-dimensional range of motion of the clavicle, scapula, and humerus during functional reach in adults aged 45–75 by Liza AM Pain, Ross Baker, Qazi Zain Sohail, Debbie Hebert and Anne MR Agur in Shoulder & Elbow

Footnotes

Acknowledgments

It is with sincere gratitude that we would like to thank Deep Kanwar Chabba, Karl Zabjek, Denise Richardson, Paul Stringer, Alexis Pain, Isaiah Gogol, Sabina Sobota, Paul van den Ende, Bushra Bayan, Sarah Roess, Hetta Patel, Karyl Taylor, Abigail James, and Annie Madapallimattam for their volunteer support during the study protocol development, recruitment, and data collection process. We would also sincerely like to thank all of the study participants for their volunteer participation in the study. Finally, we would like to dedicate this article to Prof. Deborah Hebert—a mentor, a colleague, and a friend who will be forever missed.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

This work was supported by the Ontario Ministry of Health and Long Term Care—Ontario Stroke Network (Grant No. OSN0912-000109).

Previous communication to a society or meeting

The article is not based on a previous communication to a society or meeting.

ORCID iD

Liza A.M. Pain

Supplemental material

Supplemental material for this article is available online.

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Supplementary Material

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Three-dimensional range of motion of the clavicle,scapula,and humerus during functional reach in adults aged 45–75

Abstract

Background

Methods

Results

Discussion

Keywords

Introduction

Methods

Participants

Study protocol

Data analysis

Results

Functional reach above shoulder height

Functional reach below shoulder height

Discussion

Functional reach above shoulder height

Functional reach below shoulder height

Conclusions

Supplemental Material

sj-docx-1-sel-10.1177_17585732251352452 - Supplemental material for Three-dimensional range of motion of the clavicle, scapula, and humerus during functional reach in adults aged 45–75

Footnotes

Acknowledgments

Declaration of conflicting interests

Funding

Previous communication to a society or meeting

ORCID iD

Supplemental material

References

Supplementary Material