J Shoulder Elbow Surg (2013) -, 1-8

www.elsevier.com/locate/ymse

Revisit to scapular dyskinesis: three-dimensional wing

computed tomography in prone position
Jin-Young Park, MD, PhDa,b, Jung-Taek Hwang, MD, PhDc,*, Kyung-Soo Oh, MDa,b,
Seong-Jun Kim, MDa,b, Na Ra Kim, MD, PhDd, Myung-Joo Cha, PhDe

a
Department of Orthopedic Surgery, Konkuk University School of Medicine, Seoul, South Korea
b
Global Center for Shoulder & Elbow, Department of Orthopedic Surgery, Konkuk University Hospital, Seoul, South Korea
c
Department of Orthopedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University Medical College, Chuncheon-si,
Gangwon-do, South Korea
d
Department of Radiology, Konkuk University Hospital, Seoul, South Korea
e
Gem Fitness, Seoul, South Korea

Background: Three-dimensional (3D) wing computed tomography (CT) showed a high inter-rater reli-
ability in assessing scapular dyskinesis.
Methods: The 330 scapular movements of 165 patients were classified into 4 types by 7 blinded observers.
Then, 3D wing CT was performed with patients prone, and 4 blinded observers measured 5 angles, con-
sisting of upward rotation (UR) superior translation (ST), anterior tilting (AT), protraction (PRO), and in-
ternal rotation (IR). The inter-rater reliability (IRR) of 2 methods was calculated, and cutoff values were
determined for the 5 angles on the 3D wing CT images.
Results: The IRR was 0.783 for the observational method of scapular dyskinesis and 0.981 for 3D wing
CT in the prone position. UR and ST angles were significantly larger in type 3 more than in the other types
(P < .001, P < .001), and the AT angle showed a similar pattern in type 1 (P < .001). The PRO angle was
significantly larger in types 1, 2, and 3 more than in type 4 (P < .001, P < .001, P ¼ .013), and the IR angle
was significantly larger in type 2 more than in the other types (P < .001). The cutoff values of the 5 angles
were UR, 117 ; ST, 90 ; AT, 8 ; PRO, 99 ; and IR, 51 . The UR angle showed a significant correlation with
glenohumeral internal rotation deficit (odds ratio, 0.436; P ¼ .029) and the IR angle with MDI (odds ratio,
8.947; P ¼ .048).
Conclusion: The patients with a high UR angle showed a low rate of glenohumeral internal rotation deficit
and those with a high IR angle had a high rate of the MDI in affected shoulder by the determinant of the
cutoff value of the 5 angles.
Level of evidence: Level III, Development of Diagnostic Criteria with Nonconsecutive Patients, Diagnostic
Study.
Ó 2013 Journal of Shoulder and Elbow Surgery Board of Trustees.
Keywords: Scapular dyskinesis; 3D wing CT; prone position; inter-rater reliability; cutoff value; observa-
tional method; concomitant disease

This study was approved by the Konkuk University Medical Center Medical College, 153 Gyo-dong, Chuncheon-si, Gangwon-do, 200-704
Institutional Review Board (IRB reference No.: KUH1060045). South Korea.
*Reprint requests: Jung-Taek Hwang, MD, PhD, Department of Or- E-mail address: [email protected] (J.-T. Hwang).
thopedic Surgery, Chuncheon Sacred Heart Hospital, Hallym university

1058-2746/$ - see front matter Ó 2013 Journal of Shoulder and Elbow Surgery Board of Trustees.
http://dx.doi.org/10.1016/j.jse.2013.08.016
2 J.-Y. Park et al.

The scapula is anatomically and biologically closely value can be determined from the measured angles, and that
involved with shoulder function. During the process of there will be a correlation between the newly classified
shoulder and arm movement to achieve a change in gle- scapular dyskinesis, according to the cutoff value, and
nohumeral position, as well as during motions required for concomitant diseases.
athletic and daily activities, the two are linked.11 Scapula Therefore, the aims of this study were to (1) compare the
dyskinesis is defined as observable alterations in the posi- 3D wing CT analysis in the prone position with observa-
tion of the scapula and the patterns of scapula motion in tional assessment; (2) determine the cutoff values for the
relation to the thoracic cage.11,30 Scapular dyskinesis most 5 angles that show a significant correlation with the
frequently occurs as a result of alteration of muscle acti- 4 observational types; and (3) analyze a correlation be-
vation or coordination.11 tween the affected 165 scapula and concomitant diseases of
Scapular dyskinesis has been found in patients with the affected side, according to this classification based on
various shoulder pathologies, including impingement, the cutoff value.
instability, and labral and rotator cuff injuries,2,10,15,17,21,28
and in various elbow pathologies, including ulnar collateral
Materials and methods
ligament rupture, valgus extension overload syndrome,1,18
among others. Scapular dyskinesis has been thought to
affect normal scapulohumeral rhythm (SHR) and shoulder
Study design and demographics
arthrokinematics, and therefore, to contribute to producing
This study was a diagnostic case series and prospectively
the dysfunctions associated with these pathologies.6,30
designed, repeated-measurement study of 165 patients (150 males
It is important that a proper rehabilitation is performed and 15 females) from April 2011 to December 2011. All patients
according to the type of scapular dyskinesis, especially for gave written informed consent to participate in this study. Patients
elite athletes. To assess scapular dyskinesis accurately, were an average age of 20.6 years (range, 12-66 years), an average
Kibler introduced the observational typing method, which height of 175.1 cm (range, 155.0-193.8 cm), and an average
is considered the gold standard.9,11,30 Another clinical weight of 78.1 kg (range, 54.0-101.3 kg). A total of 141 partici-
assessment method is the ‘‘yes/no’’ method, which col- pants were right-hand dominant; 162 patients showed some
lapses 3 dyskinesis categories (types 1 to 3) to a single shoulder or elbow pain on the dominant side and 3 on the
category of ‘‘yes’’ (an abnormal pattern was observed), and nondominant side. Among the 165 patients, 127 were baseball
designating the normal pattern as ‘‘no.’’21,27,30 Our previous players (27 professional, 20 university, 43 high school, 31 middle
study in 2013 showed a correlation between the scapular school, and 1 elementary school), 5 were athletes of other over-
head sports (1 swimming, 1 javelin throw, 2 handball, and
angles, which was gauged using a 3-dimensional (3D) wing
1 basketball), 5 played golf, 2 played table tennis, 1 was a diver,
computed tomography (CT) image with the patient supine, 1 participated in bowling, 1 was an archer, and 26 enjoyed oc-
and the types of scapular dyskinesis.25 casional sports activities.
The observational typing method (4 types) has shown a
relatively low inter-rater reliability (IRR; k ¼ 0.186- Exclusion criteria
0.780)3,12,25 but the measurement of angles in 3D wing CT
showed a relatively high IRR (k ¼ 0.972).25 The observa- Patients were excluded if they had (1) a previous shoulder surgery,14
tional assessment of scapular dyskinesis has several prob- (2) a previous fracture of scapula, humerus, or clavicle,30 (3) a
lems that result in a low IRR.21 First, the overlying muscles clinical reproduction or evidence of shoulder symptoms with any
and soft tissues are obstacles to the assessment.5,26 Second, cervical spine movement, (4) a history of systemic disease,31 (5) a
assessment methods should consider 3 rotational move- history of neurologic symptoms, including descriptions of numb-
ments and 2 translations of the scapula, but clinical ob- ness, tingling, or other sensory disturbance in the shoulder and
servational assessment should use static measures to upper limb in the presence of upper limb weakness,15,30 and (6) a
evaluate the scapula in 1 plane or, at most, 2 planes.5,30 scoliosis producing a visible rib hump in the neutral standing
However, the previous assessments using 3D wing CT in posture.19
the supine position had some limitations.25 First, the pro-
traction (PRO) and internal rotation (IR) angles possibly Observational assessment
decreased due to the gravity and mechanical impediment in
the supine position. Second, there were no criteria to The participants underwent a physical examination, including
tender points, range of motion, and some tests for the shoulder and
classify the several types of scapula dyskinesis. Third, there
elbow. Diagnostic imaging studies such as X-ray, magnetic reso-
was no explanation regarding a correlation between the
nance imaging, magnetic resonance arthrography, CT, and CT
measured angles and concomitant diseases. arthrography were performed to detect underling pathologies. The
We therefore hypothesized that the assessment of scap- pathologies are sorted in Table I.
ula dyskinesis using 3D wing CT imaging in the prone The 330 scapular movements of 165 patients were videotaped
position will be more accurate than that in the supine po- and classified into 4 types by 7 blinded observers. Patients were
sition, especially for PRO and IR angles, that the cutoff instructed on shoulder flexion (about a coronal axis), scapular
Scapular dyskinesis with 3D wing CT 3

The senior author (J.-Y. P.) determined the type of scapular

Table I Concomitant disease of affected side
dyskinesis at the time of testing and confirmed it at a later time by
Concomitant disease of affected side No. (%) viewing the video recordings. At a later time, 6 observers who
Elbow were not investigators (consisting of 1 certified athletic trainer
Medial collateral ligament tear 54 (32.7) with 10 years’ experience and 5 orthopedic surgeons with certified
Valgus extension overload syndrome 40 (24.2) training/fellowship in shoulder, elbow, and sports medicine)
Osteochondritis dissecans 3 (1.8) independently viewed videotaped athletes on a large screen. Each
Medial epicondylitis 2 (1.2) observer independently rated the test movements for each shoul-
Common flexor muscle strain 3 (1.8) der as having type 1, 2, 3, or 4 pattern of scapular dyskinesis as
Shoulder described by Kibler.9,11,25,30 No discussion was permitted until all
SLAP 49 (29.7) videos were rated.
Multidirectional instability 6 (3.6)
Posteroinferior labral tear 31 (18.8) Assessment with 3D wing CT
Bennett lesion 3 (1.8)
Internal impingement 8 (4.8) The 3D wing CT images were acquired using a 16- or 64-
Long head of biceps tendon tendinitis 20 (12.1) slice multidetector CT (MDCT) scanner (LightSpeed Pro16 or
Articular partial-thickness RCT 3 (1.8) LightSpeed VCT, GE Healthcare, Little Chalfont, Bucks, UK).
Impingement 44 (26.7) The scanning parameters were tube voltage, 120 kV; tube
Functional impingement 8 (4.8) current, 300 mAs; slice thickness, 2.5 mm; effective pitch,
Subcoracoid impingement 8 (4.8) 0.938 for 16-MDCT and 0.975 for 64-MDCT; and field of view,
GIRD 53 (32.1) 50 cm2. The 3D volume-rendered image was generated on a CT
Subscapularis tear 1 (0.6) workstation, with a 0.625-mm or 1.25-mm reconstruction slice
GIRD, glenohumeral internal rotation deficit; RCT, rotator cuff tear, thickness.25
SLAP, superior labrum anterior posterior. Each subject was examined in a prone position with the arms at
the side of the body and the palms toward the body. For minimiza-
tion of the motion artifact, the subjects were asked to lie on their
stomach on the slightly curvilinear table surface. Radiation dose was
plane abduction, or scaption (approximated as 40 anterior to the measured: the mean CT dose index volume ranged from 15.6 to 29.9
frontal plane), and after familiarization of movement, each mGy, and the dose-length product ranged from 350 to 750 mGy-cm.
participant was positioned for video recording. A video camera The total time into and out of the CT room varied from 3 to 5 mi-
(model DSC-W300; Sony Corporation of Korea, Seoul, South nutes, whereas the actual time required to perform a CT scan was
Korea) was used to videotape subjects in the posterior view and approximately 10 seconds. The 3D wing CT images depicted the
play back the recorded segments. Subjects stood 2 m from the thoracic region, consisting of bilateral scapula, bilateral clavicle,
camera lens, which was adjusted so that the view included each and the spine from the C7 to T7 vertebra.25
subject’s waist, head, and elbow through the full range of motion.
Male participants removed their shirts and females wore halter
tops during the study to allow observation of the posterior thorax.
3D wing CT landmarks
Each patient performed 10 repetitions of bilateral, active,
weighted shoulder flexion, and bilateral, active, weighted shoulder Because the acromioclavicular (AC) joint undergoes no trans-
abduction in the scapular plane (scaption). Tests were performed lational movement during scapular rotation, the 3 bony landmarks
with participants grasping dumbbells according to body weight, defined were the inferomedial angle (IMA) of the scapula, the AC
1.0 kg (2.2 lb) for those weighing less than 65 kg and 2.0 kg joint, and root of the scapular spine (RSS). The measurement
(4.4 lb) for those weighing more than 65 kg and in a thumbs-up criteria included 5 movements of the scapula, consisting of 3 ro-
position. Scapular dyskinesis is more clearly evident during tations and 2 translations: upward rotation (UR), internal rotation
movements with resistance than with static tests.21,25 (IR), anterior tilting (AT), superior translation (ST), and protrac-
All blinded observers underwent standardized training using a tion (PRO). Angular denominations were chosen for measure-
self-instructional slide presentation, including the definition of ments to avoid false impressions due to anatomic variations, such
scapular dyskinesis and the photograph and video examples of all as scapular size, scoliosis, and different acromion shapes.25
types of scapular dyskinesis. To avoid discrepancies in the measurement criteria, we referred
A type 1 scapular dyskinesis is characterized by prominence of to the midpoint of the AC joint as the AC joint, the most caudal
the inferior medial scapular angle and would be associated with point of the scapula as the IMA, and the most medial point of the
excessive anterior tilting of the scapula. A type 2 scapular dys- scapular spine as the RSS. The 5 angles of scapular movement
kinesis is characterized by prominence of the entire medial border were measured, as below, with reference to several previous re-
and would be associated with excessive scapular internal rotation. ports. There were a few modifications in measuring angles of
A type 3 scapular dyskinesis is characterized by prominence of the scapula because of the 3D wing CT setting (Fig. 1).25
superior scapular border and would be associated with excessive
superior translation of the scapula. A type 4 scapular dyskinesis is UR angle
characterized as normal, indicating that no asymmetries were The UR angle is measured as the angle between the extension of
identified and no prominence of the medial or superior border was line from the AC joint to RSS and the vertebral axis (C7-T7) on a
observed.9,11,25,30 posterior-coronal view (Fig. 1, A).7,27,31
4 J.-Y. Park et al.

Figure 1 The 5 angles on 3-dimensional wing computed tomography in prone position. (A) Upward rotation (UR) angle: The angle
between the extension of the line from the acromioclavicular (AC) joint to root of scapular spine (RSS) and the vertebral axis (C7-T7) on a
posterior-coronal view. (B) Internal rotation (IR) angle: The angle between the line joining the 2 AC joints and the line from the corre-
sponding AC joint to RSS on a superior-axial view. (C) Anterior tilting (AT) angle: The angle between the line from the inferomedial angle
of scapula (IMA) parallel to the medial border of scapula and the line joining the anterior tips of C7 and T7 vertebrae on a lateral-sagittal
view. (D) Superior translation (ST) angle: The angle between the line from the AC joint to midpoint of the spinous process of the C7
vertebra and the vertebral axis (C7-T7) on a posterior-coronal view. (E) Protraction (PRO) angle: The angle between the line parallel to the
vertebral axis (C7-T7) and the line from the corresponding AC joint to the center of the C7 vertebral body on a superior-axial view.

IR angle mentioned criteria to assess the presence of dyskinesis in the

The angle between the line joining the two AC joints and the line resting position of the scapula. IRR was computed for the CT
from the corresponding AC joint to RSS on a superior-axial view measurements by using the ICC. The intrarater reliabilities of the
(Fig. 1, B).7,19,31 observational assessment and 3D wing CT measurement were
calculated by assessing patients and gauging 1 angle 3 times for 1
AT angle rater. The values were also determined using the ICC as for the
The angle between the line from IMA parallel to the medial border IRR. CT measurements were compared with those of the obser-
of scapula and the line joining the anterior tips of C7 and T7 vational types using the analysis of variance. The significance of
vertebrae on a lateral-sagittal view (Fig. 1, C).7,31 CT parameters was determined by the Scheffe method of analysis.
A P value of <.05 was considered statistically significant.
A cutoff value was determined for an angle that showed a sig-
ST angle
nificant correlation with 1 of the 4 observational types. According to
The angle between the line from the AC joint to the midpoint
this classification, based on the cutoff value, a correlation between
of the spinous process of the C7 vertebra and the vertebra axis
the affected 165 scapula and concomitant diseases of the affected
(C7-T7) on a posterior-coronal view (Fig. 1, D).16,27
side was analyzed, using a c2 test and univariate logistic regression.
Analysis of variance, c2, and univariate logistic regression analysis
PRO angle were performed using SPSS 13.0 software (SPSS Inc, Chicago, IL,
The angle between the line parallel to the vertebral axis (C7-T7) USA), and the determination of the cutoff values by the receiver
and the line from the corresponding AC joint to the center of the operating characteristic curve was performed using SAS 9.3 soft-
C7 vertebral body on a superior-axial view (Fig. 1, E).16,27 ware (SAS Institute Inc, Cary, NC, USA).
These 5 angles of scapular motion were measured by 4 blinded
observers among the previous 7 blinded observers on 3D wing CT
imaging.25
Results
Statistical analysis The number of scapula with type 1, 2, 3, and 4 scapular
dyskinesis was 130, 98, 52 and 50, respectively, with the
The type of scapular dyskinesis for each individual was decided observational assessment (Table II). The IRR and intrarater
by comparing the data of the 7 observers and choosing the type reliability of observational assessment were substantial (k
with the maximum number of repetitions among the 7 readings
¼ 0.783 and 0.793).
for 1 subject (mode). IRR of the observational typing based on
the 4 possible types was calculated with intraclass correlation
The 3D wing CT assessments were measured by 4 of 7
coefficient (ICC).9,11,25,30 Agreement among examiners was blinded examiners. The IRR and intrarater reliability
defined as poor (<0.0), slight (0.0-0.2), fair (0.21-0.4), moderate calculated using the ICC for CT measurements were almost
(0.41-0.6), substantial (0.61-0.8), or almost perfect (0.81-1.0).13 perfect (k ¼ 0.981 and 0.988). The values for the 5 pa-
Four of the 7 blinded observers measured the bilateral UR, IR, rameters (UR, ST, AT, PRO and IR angles) are described in
AT, ST, and PRO angles on 3D wing CT images using the above- Table III and in Figure 2.
Scapular dyskinesis with 3D wing CT 5

Table II Observational typing

(36-61)
(44-66)
(39-61)
(39-55)
Observational typing No. (%)

IR angle,
Type 1 75 (45.5)

5
4
4
3




Type 2 46 (27.9)

48
53
50
46
Type 3 24 (14.5)
Type 4 20 (12.1)

The mean UR angle in type 3 scapular dyskinesis was

113 , and the mean values for types 1, 2, and 4 scapular
dyskinesis were 111 , 116 , and 111 , respectively (Fig. 2,

(93-113)
(95-116)
(93-112)
(91-107)
A). The mean IR angle in type 2 scapular dyskinesis was
53 , and the mean values for types 1, 3, and 4 were 48 ,

PRO angle,
50 , and 46 , respectively (Fig. 2, B). The mean AT angle in

4
4
4
4
type 1 scapular dyskinesis was 12 , and the mean values for





102
102
101
98
types 2, 3, and 4 were 4 , 0 , and 3 , respectively (Fig. 2,
C). The mean ST angle in type 3 scapular dyskinesis was
93 , and the mean values for types 1, 2, and 4 scapular
dyskinesis were 89 , 89 , and 89 , respectively (Fig. 2, D).
The mean PRO angle in type 4 scapular dyskinesis was 98 ,
and the mean values for types 1, 2, and 3 scapular dyski-

(–13 to 13)
(–14 to 11)
(–14 to 14)
nesis were 102 , 102 , and 101 , respectively (Fig. 2, E).
The UR angle and the ST angle in type 3 scapular

(6-20)
dyskinesis, the AT angle in type 1 scapular dyskinesis, and

AT angle,
the IR angle in type 2 scapular dyskinesis were significantly

3
5
7
4
increased compared with those in the other types of scap-





The 5 angles of the scapula with 3-dimensional wing computed tomography analysis
ular dyskinesis (P < .001; Fig. 2, A-D). The PRO angle in

12
4
0
3
AT, anterior tilting; IR, internal rotation; PRO, protraction; ST, superior translation; UR, upward rotation.
types 1, 2, and 3 scapular dyskinesis was significantly
increased compared with the angle in type 4 scapular
dyskinesis (P < .001, P < .001, P ¼ .013; Fig. 2, E).
The cutoff values were determined for each angle among
the types showing significant differences using the ROC
(80-102)
(79-105)
(85-103)
(78-103)
curve (Table IV). The cutoff values of the 5 angles were
UR, 117 ; ST, 90 ; AT, 8 ; PRO, 99 ; and IR, 51 . The
ST angle,

statistical analysis showed a correlation between a classi-

5
5
4
5

fication using the cutoff value and the concomitant diseases






of affected side using c2 square, the UR angle showed a

90
89
93
90

) Data are expressed mean  standard deviation, with their ranges.

correlation with osteochondritis dissecans (OCD) of the

elbow (P ¼ .040) and glenohumeral internal rotation deficit
(GIRD; P ¼ .027), and the AT (P ¼ .029) and IR (P ¼ .028)
angles showed a correlation with multidirectional insta-
bility (MDI) of the shoulder. In addition, a relation between
(106-170)

the IR angle and a Bennett lesion of the shoulder showed a

(96-165)
(98-141)

(96-128)

borderline significance (P ¼ .051). Among them, the UR

angle showed a significant correlation with GIRD (odds
ratio, 0.436; P ¼ 0.029) and IR angle with MDI (odds ratio,
UR angle,
111  8
116  8
123  9
111  6.8

8.947; P ¼ .048) on univariate logistic regression (Table V).

Discussion

Efforts continue to assess scapular dyskinesis precisely for

the enhancement of sports performance, the treatment of
Table III

concomitant disorders, and the prevention of sports injury,

1
2
3
4
Type)
Type
Type
Type
Type

among other reasons.4,22,23 Recently, observational

methods and 3D tracking systems have been widely used.
6 J.-Y. Park et al.

Figure 2 The correlation between the 5 angles on 3-dimensional wing computed tomography and the observational typings. (A) The
upward rotation angle in type 3 scapular dyskinesis was increased compared with those in the other types of scapular dyskinesis, and the
difference was statistically significant (P < .001). (B) The internal rotation angle in type 2 scapular dyskinesis was increased compared with
those in the other types of scapular dyskinesis, and the difference was statistically significant (P < .001). (C) The anterior tilting angle in
type 1 scapular dyskinesis was increased compared with those in the other types of scapular dyskinesis, and the difference was statistically
significant (P < .001). (D) The superior translation angle in type 3 scapular dyskinesis was increased compared with those in the other types
of scapular dyskinesis, and the difference was statistically significant (P < .001). (E) The protraction angles in types 1, 2, and 3 scapular
dyskinesis were increased compared with that in type 4 scapular dyskinesis, and the differences were statistically significant (P < .001, P <
.001, P ¼ .013).

Table IV Cutoff values by receiver operating characteristic curve

Angle Group vs group Cutoff value by ROC curve, Sensitivity (%) Specificity (%)
UR angle Type 3 vs type 1, 2, 4 117 84.6 74.1
ST angle Type 3 vs type 1, 2, 4 90 80.8 63.0
AT angle Type 1 vs type 2, 3, 4 8 94.6 84.5
PRO angle Type 1, 2, 3 vs type 4 99 70.0 74.0
IR angle Type 2 vs type 1, 3, 4 51 75.5 75.0
AT, anterior tilting; IR, internal rotation; PRO, protraction; ROC, receiver operating characteristic; ST, superior translation; UR, upward rotation.

Although the observational method is simple and easy, it significantly in types 1 (P < .001), 2 (P < .001), and 3 (P ¼
showed a relatively low IRR (k ¼ 0.186-0.780)3,12,25 and is .013) compared with that in type 4, whereas the IR angle
interrupted by a thick soft tissue.26 However, the 3D increased only in type 1 in our previous study. Second, the
tracking system of scapular movement that can assess a cutoff values were determined for each angle to classify
dynamic movement of the scapular is invasive with a bone scapular dyskinesis according to the 5 angles. Third, the
pin7 or is relatively inaccurate with surface measurement correlation among the classification according to the 5 angles
techniques.8,15,20 Therefore, a method to directly assess the and concomitant diseases was analyzed statistically.
scapula is necessary, and in our previous study, the mea- The significant correlations among the measured angles
surement using 3D wing CT in the supine position showed and concomitant diseases in this study correspond to pre-
a high IRR (k ¼ 0.972).25 vious studies.24,29 A study in 2010 presented that collegiate
The CT measurement in this study showed a similar baseball players had more glenohumeral internal rotation
pattern with our previous study, but with some differences.25 deficit than high school players and that the former had less
First, the IR angle in type 2 increased significantly (P <.001) scapular upward rotation than the latter.29 This result sug-
compared with those in other types, whereas the UR angle gests that players who have more glenohumeral internal
and ST in type 3, and the AT angle in type 1 are similar to our rotation deficit show less scapular upward rotation. Another
previous study. Second, the PRO angle increased study reported that individuals with MDI demonstrated a
Scapular dyskinesis with 3D wing CT 7

There are several important positions of the scapula, such

Table V Correlation with concomitant diseases analyzed
by cut-off values
as standing with arms at the side or with arms abducted,
supine with arms abducted, and prone with arms abducted.
Angle related with P (c2) Univariate logistic However, other positions were not attempted in this study.
concomitant disease regression
A further study will be needed.
Odds ratio P
UR angle with OCD of elbow .040 9748602 .996
UR angle with GIRD of .027 0.436 .029 Conclusion
shoulder
AT angle with MDI of shoulder .029 0.000 .997 3D wing CT imaging in the prone position can provide an
IR angle with MDI of shoulder .028 8.947 .048
accurate assessment of scapular dyskinesis with a high
IR angle with Bennett lesion .051 82142789 .996
IRR. The analysis of 3D wing CT in the prone position
of shoulder
showed a more significant correlation with the observa-
AT, anterior tilting; GIRD, glenohumeral internal rotation deficiency;
tional typing than that of the 3D wing CT in the supine
IR, internal rotation; MDI, multidirectional instability; OCD, osteo-
chondritis dissecans; UR, upward rotation. position.25 The cutoff values could be determined accord-
ing to 3D wing CT analysis. As a result of the statistical
analysis showing a correlation between a classification
significant decrease in scapular upward rotation in scapular using the cutoff value and the concomitant diseases of the
plane abduction and a significant increase in scapular in- affected side, patients with a high UR angle were found to
ternal rotation during scapular plane abduction compared show a low rate of GIRD and those with a high IR angle had
with asymptomatic controls.24 a high rate of the MDI in the affected shoulder by the
The present study is important in several points. First, the determinant of the cutoff value of the 5 angles.
3D wing CT image in the prone position showed an
unblocked increase in the IR and PRO angles, especially in
type 2, compared with that in the supine position. Second,
the new classification was made using the cutoff values, Acknowledgment
which can be used for the diagnosis, treatment, and reha-
bilitation of patients with scapular dyskinesis. Third, corre- The authors thank 2 orthopedic surgeons, Kwang-Mo
lations of scapula dyskinesis with concomitant diseases were Kim and Dheeraj Makkar, and 1 sports trainer, Kyung-
partly found, and these correlations can be used for searching Jin Han, for participating in the observational typing of
the pathology and treatment of concomitant diseases. scapular dyskinesis.
This study has several limitations: First, 3D wing CT
imaging in the prone position was beneficial in eliminating
the effect of gravity, but gravity could exaggerate the IR
and PRO angles in type 2. Disclaimer
Second, the only participants of this study were symp-
tomatic athletes. There was no nonsymptomatic control This work was supported by Konkuk University in 2011.
group. The authors, their immediate families, and any
Third, there was an exposure to radiation. To perform research foundations with which they are affiliated have
3D wing CT imaging, the scapula, spine, breast, and other not received any financial payments or other benefits from
tissues should be scanned, and therefore, are exposed to any commercial entity related to the subject of this article.
radiation. A radiation dose of average CT scan was about
1000 millirems, and the international standard annual dose
limit is 5000 millirems. Therefore, the CT scan can be
performed 2 to 3 times per year with an interval of more
than 3 months. References
Fourth, the 3D wing CT method is more expensive than
the observational assessment. However, 3D wing CT anal- 1. Barnett ND, Duncan RD, Johnson GR. The measurement of three
dimensional scapulohumeral kinematics–a study of reliability. Clin
ysis can be cost-effective owing to a higher IRR than the Biomech (Bristol, Avon) 1999;14:287-90.
observational method. 2. de Groot JH. The variability of shoulder motions recorded by means of
Fifth, 3D wing CT methods assess static motion rather palpation. Clin Biomech (Bristol, Avon) 1997;12:461-72.
than dynamic motion. However, this study and our previous 3. Ellenbecker TS, Kibler WB, Bailie DS, Caplinger R, Davies GJ,
study proved the statistically significant correlation between Riemann BL. Reliability of scapular classification in examination of
professional baseball players. Clin Orthop Relat Res 2012;470:1540-4.
the static position and the dynamic motion of scapula. http://dx.doi.org/10.1007/s11999-011-2216-0
Finally, the 3D wing CT imaging in this study was 4. Fayad F, Roby-Brami A, Gautheron V, Lefevre-Colau MM,
performed only with patients prone with arms at their sides. Hanneton S, Fermanian J, et al. Relationship of glenohumeral
8 J.-Y. Park et al.

elevation and 3-dimensional scapular kinematics with disability in 19. Mandalidis DG, Mc Glone BS, Quigley RF, McInerney D, O’Brien M.
patients with shoulder disorders. J Rehabil Med 2008;40:456-60. Digital fluoroscopic assessment of the scapulohumeral rhythm. Surg
http://dx.doi.org/10.2340/16501977-0199 Radiol Anat 1999;21:241-6.
5. Hill AM, Bull AM, Dallalana RJ, Wallace AL, Johnson GR. Glenohumeral 20. Matsui K, Shimada K, Andrew PD. Deviation of skin marker from
motion: review of measurement techniques. Knee Surg Sports Traumatol bone target during movement of the scapula. J Orthop Sci 2006;11:
Arthrosc 2007;15:1137-43. http://dx.doi.org/10.1007/s00167-007-0318-8 180-4. http://dx.doi.org/10.1007/s00776-005-1000-y
6. Hogfors C, Peterson B, Sigholm G, Herberts P. Biomechanical model 21. McClure P, Tate AR, Kareha S, Irwin D, Zlupko E. A clinical method
of the human shoulder joint–II. The shoulder rhythm. J Biomech 1991; for identifying scapular dyskinesis, part 1: reliability. J Athl Train
24:699-709. 2009;44:160-4. http://dx.doi.org/10.4085/1062-6050-44.2.160
7. Karduna AR, McClure PW, Michener LA. Scapular kinematics: ef- 22. Meyer KE, Saether EE, Soiney EK, Shebeck MS, Paddock KL,
fects of altering the Euler angle sequence of rotations. J Biomech Ludewig PM. Three-dimensional scapular kinematics during the
2000;33:1063-8. throwing motion. J Appl Biomech 2008;24:24-34.
8. Karduna AR, McClure PW, Michener LA, Sennett B. Dynamic 23. Michener LA, Walsworth MK, Burnet EN. Effectiveness of rehabili-
measurements of three-dimensional scapular kinematics: a validation tation for patients with subacromial impingement syndrome: a sys-
study. J Biomech Eng 2001;123:184-90. tematic review. J Hand Ther 2004;17:152-64. http://dx.doi.org/10.
9. Kibler WB, Chandler TJ. Range of motion in junior tennis players 1197/j.jht.2004.02.004
participating in an injury risk modification program. J Sci Med Sport 24. Ogston JB, Ludewig PM. Differences in 3-dimensional shoulder ki-
2003;6:51-62. http://dx.doi.org/10.1016/S1440-244080008-7 nematics between persons with multidirectional instability and
10. Kibler WB, Ludewig PM, McClure P, Uhl TL, Sciascia A. Scapular asymptomatic controls. Am J Sports Med 2007;35:1361-70. http://dx.
Summit 2009: introduction. July 16, 2009, Lexington, Kentucky. J doi.org/10.1177/0363546507300820
Orthop Sports Phys Ther 2009;39:A1-13. http://dx.doi.org/10.2519/ 25. Park JY, Hwang JT, Kim KM, Makkar D, Moon SG, Han KJ. How to
jospt.2009.0303 assess scapular dyskinesis precisely: 3-dimensional wing computer
11. Kibler WB, McMullen J. Scapular dyskinesis and its relation to tomography-a new diagnostic modality. J Shoulder Elbow Surg 2013;
shoulder pain. J Am Acad Orthop Surg 2003;11:142-51. 22:1084-9. http://dx.doi.org/10.1016/j.jse.2012.10.046
12. Kibler WB, Uhl TL, Maddux JW, Brooks PV, Zeller B, McMullen J. 26. Shaheen AF, Alexander CM, Bull AM. Tracking the scapula using the
Qualitative clinical evaluation of scapular dysfunction: a reliability scapula locator with and without feedback from pressure-sensors: a
study. J Shoulder Elbow Surg 2002;11:550-6. http://dx.doi.org/10. comparative study. J Biomech 2011;44:1633-6. http://dx.doi.org/10.
1067/mse.2002.126766 1016/j.jbiomech.2011.02.139
13. Landis JR, Koch GG. The measurement of observer agreement for 27. Tate AR, McClure P, Kareha S, Irwin D, Barbe MF. A clinical method
categorical data. Biometrics 1977;33:159-74. for identifying scapular dyskinesis, part 2: validity. J Athl Train 2009;
14. Laudner KG, Stanek JM, Meister K. Differences in scapular upward 44:165-73. http://dx.doi.org/10.4085/1062-6050-44.2.165
rotation between baseball pitchers and position players. Am J Sports 28. Teece RM, Lunden JB, Lloyd AS, Kaiser AP, Cieminski CJ,
Med 2007;35:2091-5. http://dx.doi.org/10.1177/0363546507305098 Ludewig PM. Three-dimensional acromioclavicular joint motions
15. Ludewig PM, Behrens SA, Meyer SM, Spoden SM, Wilson LA. during elevation of the arm. J Orthop Sports Phys Ther 2008;38:181-
Three-dimensional clavicular motion during arm elevation: reliability 90. http://dx.doi.org/10.2519/jospt.2008.2386
and descriptive data. J Orthop Sports Phys Ther 2004;34:140-9. http:// 29. Thomas SJ, Swanik KA, Swanik CB, Kelly JD. Internal rotation and
dx.doi.org/10.2519/jospt.2004.1020 scapular position differences: a comparison of collegiate and high
16. Ludewig PM, Phadke V, Braman JP, Hassett DR, Cieminski CJ, school baseball players. J Athl Train 2010;45:44-50. http://dx.doi.org/
LaPrade RF. Motion of the shoulder complex during multiplanar hu- 10.4085/1062-6050-45.1.44
meral elevation. J Bone Joint Surg Am 2009;91:378-89. http://dx.doi. 30. Uhl TL, Kibler WB, Gecewich B, Tripp BL. Evaluation of clinical
org/10.2106/JBJS.G.01483 assessment methods for scapular dyskinesis. Arthroscopy 2009;25:
17. Ludewig PM, Reynolds JF. The association of scapular kinematics and 1240-8. http://dx.doi.org/10.1016/j.arthro.2009.06.007
glenohumeral joint pathologies. J Orthop Sports Phys Ther 2009;39: 31. Yano Y, Hamada J, Tamai K, Yoshizaki K, Sahara R, Fujiwara T, et al.
90-104. http://dx.doi.org/10.2519/jospt.2009.2808 Different scapular kinematics in healthy subjects during arm elevation
18. Lyman S, Fleisig GS, Andrews JR, Osinski ED. Effect of pitch type, and lowering: glenohumeral and scapulothoracic patterns. J Shoulder
pitch count, and pitching mechanics on risk of elbow and shoulder Elbow Surg 2010;19:209-15. http://dx.doi.org/10.1016/j.jse.2009.09.
pain in youth baseball pitchers. Am J Sports Med 2002;30:463-8. 007