SCAPULAR_SURFACE_PALPATION_

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Scapular position: the validity of skin sur
J. Lewis,* A. Green,{ Z. Reichard,{ C. Wright}
*Department of Physiotherapy, Chelsea and Westminster
Health and Social Sciences, Coventry University, {Lecture
}Principal Lecturer in Health Sciences and Deputy Dir
University
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spinous process (SP), the SP corresponding with the root of the spine of the scapula, and the SP corresponding with
the inferior angle and the surface points would be 1.46 cm, 1.09 cm and 1.01 cm respectively. The results of this
Manual Therapy (2002) 7(1), 26–30
# 2002 Elsevier Science Ltd
doi:10.1054/math.2001.0405, available online at http://www.idealibrary
study suggest that surface palpation of scapular location is a valid method for determining the actual location of the
scapula. The findings also suggest that surface palpation can determine the location of thoracic landmarks, which
may serve as reference points for scapular position. # 2002 Elsevier Science Ltd.
INTRODUCTION
Various clinical scenarios have been proposed sug-
gesting how changes in the resting position and
movement of the scapula are associated with a
number of pathological conditions of the shoulder,
including subacromial impingement and glenohum-
eral instability (Solem-Bertoft et al. 1992; Kibler
1998). Although limited evidence is available to
support these claims, assessment of scapular position
is considered to be an essential part of the clinical
examination of the shoulder (Kibler 1991; Host 1995;
Kibler 1998).
A number of palpation studies have demonstrated
satisfactory intra-tester (DiVeta et al. 1990; Green-
field et al. 1995) and inter-tester (Greenfield et al.
1995) reliability in determining scapular position. The
validity of using surface landmarks as predictors of
the bony landmarks have been investigated in
radiological studies (Greenfield et al. 1995; Sobush
et al. 1996). However, potential problems exist when
using radiographs as measures of posture and they
have not been proven to be the ‘gold standard’.
Radiographs are two-dimensional representations of
the three-dimensional body and are subject to both
magnification and true distortion (Curry et al. 1984).
Further, slight postural variations such as rotation
away or towards the film would influence the results
and would have the potential to influence the
reliability and validity of the measurements (Curry
et al. 1984). Another source of error when using
Received: 20 September 2000
Revised: 20 March 2001
Accepted: 10 May 2001
Jeremy Lewis, MAPA, MCSP, MMPAA, MMACP, MSc
(Manipulative Physiotherapy), Pg Dip in Sports Physiotherapy,
PgDip in Biomechanics, Department of Physiotherapy, Chelsea and
Westminster, Healthcare NHS Trust.
Ann Green, MSc, MCSP, Principal Lecturer, School of Health and
Social Sciences, Coventry University
Zali Reichard, MA, BPT, Lecturer, School of Physiotherapy,
Tel Aviv University, Israel
Christine Wright, BSc (Hons), C. Math, MIMA, FSS, Principal
Lecturer in Health Sciences and Deputy Director of the
Psychosocial Research Centre: Chronic Conditions and Disability,
School of Health and Social Sciences, Coventry University
Correspondence to: Jeremy Lewis, Research Co-ordinator,
Department of Physiotherapy, Chelsea and Westminster
SUMMARY. The assessment of the resting position
quadrant posture. The purpose of this study was to det
scapular position. Twelve embalmed shoulders were ex
landmarks and three bony thoracic landmarks were comp
based on the upper value for a distance (with 95% confi
location of the root of the spine of the scapula, the acrom
0.98 cm and 0.46 cm respectively from the centre of the b
Healthcare NHS Trust, 369 Fulham Road, London SW10 9NH,
England, Tel: 020 8746 8406; Fax: 020 8746 8880;
Email: jeremy.lewis@chelwest.nhs.uk
26
face palpation
Healthcare NHS Trust, {Principal Lecturer, School of
r, School of Physiotherapy, Tel Aviv University, Israel,
ector of the Psychosocial Research Centre, Coventry
the scapula forms part of the examination of upper
mine if surface palpation is a valid indicator of actual
mined and the actual location of three bony scapular
ed with surface palpation of these locations. The results,
ence), suggested that the difference between the surface
l angle and the inferior angle would be less than 0.67 cm,
y locations. The difference between the twelfth thoracic
.com on
radiographs to determine scapular position would be
blurring around the bone known as the zone of
Scapular position: the validity of skin surface palpation 27
geometric unsharpness, penumbra, or edge gradient.
This occurs because the X-rays do not strike the bone
perpendicularly to its surface. Another geometric
factor that may influence the quality of the radio-
graphic image is motion which is known as motion
unsharpness and potentially may be caused by
respiration or postural sway (Curry et al. 1984).
Limitations therefore exist in validating the ability to
palpate scapular position with radiographs.
Many therapists use surface palpatory techniques
to determine the resting position of the scapula. If
this procedure forms the basis of a clinical assessment
technique it is necessary to determine its validity in
order to support its continued use. As such the
purpose of this study was to determine if palpatory
techniques are valid methods to locate bony land-
marks on the scapula and thoracic spine.
METHODS AND MATERIALS
Subjects
The subjects for this experiment consisted of 12
embalmed cadavers at the Department of Anatomy,
Sackler Faculty of Medicine, Tel Aviv University,
Israel. Five male subjects and seven female subjects,
all over the age of 60 years, were examined. In all,
seven left shoulders and five right shoulders were
examined. No obvious shoulder, thoracic, or upper
limb injury was observed in any of the specimens.
Permission to conduct this study was granted by the
Department of Anatomy, Tel Aviv University, Israel.
Measurements and Procedures
The cadavers were placed on metal examination
tables in the prone position with the upper limbs by
the sides. Metal pins, positioned through the skin
were used to directly compare the accuracy of the
skin surface locations with the bony locations. Skin
flap incisions were made prior to the palpatory
investigation so as not to dislodge the pins.
The skin and subcutaneous tissues around the
cervical, thoracic and scapular region were resected
down to the level of the muscle tissue. A vertical
incision was made lateral to spinous processes from
the occiput down to the level of the lumbar spine. A
number of horizontal incisions were made from the
occiput to the superior aspect of the shoulder, from
the area under the inferior angle of the scapula
laterally to the lateral aspect of the thoracic wall and
from the area of the lumbar spine laterally to the
thoracic wall. These tissues were then resected to fully
expose the thoracic spinous processes (SP) and the
entire posterior surface of the scapula. The flap was
left intact at the level of the lateral aspect of the
shoulder and the lateral wall of the thorax. The flap
# 2002 Elsevier Science Ltd
was then repositioned over the scapula and thoracic
spine.
Palpation was performed using latex examination
gloves (Easy Touch, USA). The landmarks that were
examined were the root of the spine of the scapula,
the tubercle on the posterior aspect of the acromion
and the inferior angle of the scapula. The inferior
angle was palpated first by following the medial and
lateral borders of the scapula inferiorly to find their
union. To confirm the location it was also palpated
through the soft tissue under the scapula in a superior
direction until the angle was identified. The anterior
aspect of the acromion was then palpated and was
followed posteriorly until the acromial angle was
located. The spine of the scapula was then identified
and followedlaterally to confirm the location of the
tubercle. The spine of the scapula was then followed
medially to the medial border of the scapula where
the root of the spine was palpated.
The other landmarks that were examined were the
SP corresponding with the root of the spine of
the scapula, the SP corresponding with the inferior
angle of the scapula and the twelfth thoracic SP.
A horizontal line was visualized from the root of the
spine to the thoracic spinous processes. The SP
closest to this line was palpated. Its actual number
was not determined, as the purpose of this study was
to follow the approach of Greenfield et al. (1995) who
did not determine the specific SP but identified the SP
that corresponded with the scapular bony points. A
similar process was followed to locate the SP
corresponding with the inferior angle. The SP that
was located closest to a perpendicular line from the
inferior angle to the vertebral column was selected
and marked. The twelfth thoracic SP was located by
counting down the vertebrae as well as counting
upwards from the lumbar spine. When the skin was
removed its position was confirmed by recounting as
well as observation of the insertion of the most
inferior fibres of the lower trapezius muscle.
Each landmark was given an alphabetical reference
(Fig. 1). The locations were marked as follows:
Point A: The thoracic SP corresponding with the
root of the spine of the scapula (T2 or T3)
Point B: The root of the spine of the scapula
Point C: The acromial angle
Point D: The thoracic SP corresponding with the
inferior angle of the scapula (T7 or T8)
Point E: The inferior angle of the scapula
Point F: The twelfth thoracic SP
Each anatomical landmark was palpated through
the skin by the first investigator who then placed
red-topped metal pin markers at each of the six
anatomical sites (Fig. 2).
Manual Therapy (2002) 7(1), 26–30
28 Manual Therapy
Following this the second observer peeled back the
skin flap and carefully placed green-topped markers
in the holes left by the original markers (Fig. 3).
With the skin flap removed, the six bony land-
marks were identified visually and their centres
agreed upon by both observers. The distance from
the centre of the bony landmark to the insertion point
of the green-topped pin marker was measured using a
Vernier calliper (Mitutoyo, Japan). The Vernier
calliper had a reported accuracy of measurement of
0.1 mm (Manufacturer’s information).
Fig. 1—The location of the three scapular points and the three
thoracic spinous processes.
Fig. 2—Placement of the metal marker pins following surface
anatomy palpation of the scapula and thoracic spine.
Manual Therapy (2002) 7(1), 26–30
If the green-topped marker position differed from
the bony landmark the distance and direction from
the landmark was recorded. The measurement was
made by the second observer.
RESULTS
The distance from the green marker pin to the centre
of the bony landmark, as well as the direction from
the pin marker, to the landmark are detailed in
Table 1. The validity of the skin surface measurement
was investigated by determining the mean distance
and standard deviation of the skin marker from the
bony landmark. Medial and inferior displacement
from the bony landmark was assigned a negative
direction. Superior and lateral displacement was
assigned a positive direction. The confidence level
was set at 95% (Altman 1991). The mean distance
with direction and standard deviations are detailed in
Table 2.
Fig. 3—Placement of the metal marker pins into the locations of
the skin marker pins once the skin flap had been removed.
DISCUSSION
The present study addressed the issue of the validity
of skin surface palpation to determine scapular
position by comparing three anatomical landmarks
overlying the scapula with the actual bony land-
marks. The three scapular landmarks were the root of
the spine of the scapula, the acromial angle and the
inferior angle of the scapula. The correspondence of
the surface anatomy to bony landmarks was assessed
by comparing the mean difference in the distance
between the surface point to the bony point. The 95%
confidence level was set for the analysis of the results.
The results for upper limits suggest that for a given
subject, the difference between the surface locations
of the root of the spine of the scapula (Point B),
the acromial angle (Point C) and the inferior angle
# 2002 Elsevier Science Ltd
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Scapular position: the validity of skin surface palpation 29
Table 1. The distance and direction from the green pin-marker to t
Subject Pin to A Pin to B Pin
1 0.5 0.3 0
Inferior Lateral
2 0.4 0.7 0
Medial Superior Me
3 1.1 0.0 0
Superior Sup
4 0.4 0.2 0
Inferior Inferior
5 0.7 0.0 0
Superior Lat
6 0.0 0.5 0
Inferior Me
7 0.2 0.3 0
Inferior Lateral
8 0.0 0.0 0
Sup
9 0.4 0.2 0
Superior Medial
10 0.0 0.2 0
Medial
11 0.6 0.1 0
Inferior Lateral Infe
12 0.5 0.4 0
Inferior Inferior Lat
(Point E), would be less than 0.67 cm, 0.98 cm and
0.46 cm from the bony locations respectively. Anato-
mically, the root of the spine, the acromial angle and
the inferior angle are not points but areas of bone and
the distance to the pin mark was measured from the
observed centre of the bony landmark. In most cases
the pin marker was located within the same bony area
but at a distance from its observed centre.
To determine side to side differences in the position
of the scapula, changes in the position of the scapula,
and to compare the resting position of the scapula in
different population groups or after therapeutic
intervention, reference points are necessary. DiVeta
et al. (1990) used the third thoracic SP as a reference
point to determine the degree of protraction of the
scapula. Greenfield et al. (1995) used the area of
the thoracic spine corresponding with the root of the
spine and the area of the thoracic spine correspond-
ing with the inferior angle of the scapula as reference
points for determining protraction and rotation of
the scapula.
Table 2. The mean distance with assigned direction and standard
deviation from each bony landmark
Pin Mean distance SD* 2 SD* Upper limit
A 70.033 0.528 1.056 1.09 cm
B 70.008 0.332 0.664 0.67 cm
C 0.108 0.438 0.876 0.98 cm
D 70.075 0.465 0.930 1.01 cm
E 0.042 0.211 0.422 0.46 cm
F 70.208 0.624 1.248 1.46 cm
(Legend: *SD¼ standard deviation)
# 2002 Elsevier Science Ltd
The spinous processes corresponding with the root
of the spine (Point A), the inferior angle (Point D)
and the twelfth thoracic SP (Point F), based upon an
upper limit of mean distance and standard deviation
(SD), would be useful reference points to determine
the resting position of the scapula and changes in its
position. The results of this study suggest that, with
95% confidence, the difference between the surface
location and the bony location of Point A (the
thoracic SP corresponding with the root of the spine
landmark. (Measurements in cm)
C Pin to D Pin to E Pin to F
0.2 0.0 0.8
Medial Inferior
0.2 0.2 0.7
l Superior Inferior Superior
0.9 0.2 0.3
or Inferior Superior Lateral
0.5 0.0 0.2
Inferior Inferior
0.3 0.3 0.5
l Superior Inferior Inferior
0.2 0.2 1.4
l Inferior Inferior Inferior
0.3 0.2 0.4
Inferior Lateral Superior
0.2 0.4 0.2
or Lateral Superior Superior
0.2 0.0 0.5
Superior Inferior
0.7 0.1 0.8
Inferior Lateral Inferior
0.4 0.0 0.4
r Superior Superior
0.6 0.3 0.3
l Lateral Superior Inferior
of the scapula), Point D (the thoracic SP correspond-
ing with the inferior angle of the scapula) and Point F
(the twelfth thoracic SP) would be less than 1.09 cm,
1.01 cm and 1.46 cm, respectively. Although these
distances are larger than the scapular landmarks they
are of relatively small magnitudecompared with the
movement of the scapula (Doody et al. 1970;
Kapandji 1982; Bagg & Forrest 1988; Michiels &
Grevenstein 1995) and the results of this investigation
suggest that the thoracic surface landmarks could
serve as useful reference points for the relative
position of the scapula.
It was not possible to repeat the measurements in
this study as the holes left in the skin would have lead
to examiner bias and reduced the external validity of
the results. As a result of this the intra- or inter-tester
reliability was not tested. However, previous studies
(DiVeta et al. 1990; Greenfield et al. 1995, Sobush et
al. 1996) have demonstrated that one observer is
capable of identifying the same scapular and thoracic
surface landmark reliably on a number of occasions
as are multiple observers (Greenfield et al. 1995).
However, additional research is necessary to further
support these conclusions.
Manual Therapy (2002) 7(1), 26–30
Another limitation of this study was the potential
difference in quality and texture of the skin of the
embalmed specimens in this study from that of living
subjects. This may have had an influence on the
palpatory findings. Further, palpation in this study
was performed through latex examination gloves and
both these factors may influence findings in living
subjects. However, other studies have used cadaveric
material to provide anatomical information related to
clinical tests (Valadie et al. 2000). Clinically scapula
position are not clinically relevant when considering
the excursion of the scapula in functional movement.
Further, the ability to determine the position of
selected thoracic spinous processes provides a poten-
tial reference system for determining changes in the
position of the scapula.
Acknowledgements
The authors would like to acknowledge and thank Katie Money-
30 Manual Therapy
palpation may be performed in standing, sitting or
prone. For practical reasons the prone lying position
was the only position tested in this study. Due to the
nature of this study the landmarks were possibly
more easily determined than in living subjects who
would move through the action of respiration and
postural sway. Considerable time was taken to
palpate each landmark in this investigation, often
from a number of different directions. The opportu-
nity to do this in a clinical examination may not be
feasible and to some extent may have influenced the
results.
The thickness of the subcutaneous tissue under
each surface point was not measured in this study. It
is therefore not possible to determine if the thickness
of the subcutaneous tissue had an influence on the
ability to accurately identify the bony locations. This
should be investigated in future research.
Palpation was only performed with the arms by the
sides of the body, which is similar to the clinical
assessment of the resting position of the scapula.
Future reliability and validity studies are required in
other static positions as well as during functional
movements.
CONCLUSION
A number of studies have shown the reliability of
palpating skin surface locations. The findings of this
cadaveric study suggest that skin surface landmarks
are useful and valid reference points for determining
the location of selected bony areas on the scapula and
thoracic spine. Although ‘pin-point’ accuracy was not
shown, surface anatomy palpation appears to provide
an acceptable method for determining the relative
position of the scapula. The small discrepancies in
Manual Therapy (2002) 7(1), 26–30
Kyrle, who contributed a diagram for this paper.
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# 2002 Elsevier Science Ltd
	INTRODUCTION
	METHODS AND MATERIALS
	Subjects
	Measurements and Procedures
	Figure 1
	Figure 2
	Figure 3
	RESULTS
	DISCUSSION
	Table 1
	Table 2
	CONCLUSION
	Acknowledgements
	References