Journal of Back and Musculoskeletal Rehabilitation 35 (2022) 1399–1406 1399

DOI 10.3233/BMR-220006
IOS Press

Effect of thoracic expansion restriction on

scapulothoracic and glenohumeral joint
motion during shoulder external rotation
Mitsuhiro Yoshimi, Noriaki Maeda, Makoto Komiya, Kazuki Fukui, Tsubasa Tashiro, Kazuki Kaneda,
Satoshi Arima, Shogo Tsutsumi, Takeru Abekura and Yukio Urabe∗
Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan

Received 10 January 2022

Accepted 4 May 2022

Abstract.
BACKGROUND: Shoulder external rotation in the throwing motion involves movement of the scapulothoracic and glenohumeral
joints, thoracic spine, and the thorax. Restriction of thoracic expansion may decrease scapulothoracic joint motion and compensate
by excessive glenohumeral joint motion. However, it is unclear how restricting the expansion of the thorax alters shoulder motion.
OBJECTIVE: To elucidate changes in scapulothoracic and glenohumeral joint movements caused by restricted thoracic expansion.
METHODS: Kinematic data were obtained using an electromagnetic tracking device (Liberty; Polhemus), from 18 male
participants, during shoulder external rotation in the sitting position with and without restriction of thoracic expansion. The
displacements from the start position to the maximum external rotation position were compared, and Pearson’s correlation
coefficient was calculated.
RESULTS: A significant difference was observed in the scapulothoracic posterior tilt angle (P < 0.01) and glenohumeral external
rotation angle (P < 0.01). A significant positive correlation existed between scapulothoracic posterior tilt and glenohumeral
external rotation (P < 0.05) with and without restriction.
CONCLUSIONS: Restriction of thoracic expansion decreased scapulothoracic motion and increased glenohumeral motion.
Thus, a decrease in thoracic expansion may change scapulothoracic and glenohumeral movements, which may be a risk factor for
throwing injuries.

Keywords: Scapulothoracic joint, glenohumeral joint, restriction of thoracic expansion, shoulder external rotation

1. Introduction The acceleration phase begins after the shoulder joint

has reached its maximum external rotation (MER) po-
Throwing injuries of the shoulder are caused by re- sition [5]. After MER, the movement of the shoulder
peated throwing motions in overhead sports such as joint changes abruptly from external to internal rotation,
baseball [1–3]. Most baseball players with such injuries resulting in a large internal rotation torque and forward
complain of symptoms from the late cocking phase shear force on the shoulder [6]. Chronic application of
to the acceleration phase [4]. The late cocking phase, mechanical stress due to repetitive throwing motions
which begins after stride foot contact on the ground, result in throwing injuries of the shoulder. Therefore, in
involves trunk rotation and shoulder external rotation. order to prevent these injuries, it is necessary to analyze
the shoulder joint motion from the late cocking phase
∗ Corresponding to the early acceleration phase, particularly focusing on
author: Yukio Urabe, 1-2-3 Kasumi, Minami-ku,
Hiroshima 734-8553, Japan. Tel.: +81 82 257 5405; Fax: +81 82 257 the MER.
5405; E-mail: [email protected]. The shoulder joint motion involves the glenohumeral

ISSN 1053-8127 c 2022 – The authors. Published by IOS Press. This is an Open Access article distributed under the terms of the Creative
Commons Attribution-NonCommercial License (CC BY-NC 4.0).
1400 M. Yoshimi et al. / Effect of thoracic expansion restriction on scapulothoracic and glenohumeral joint motion

and the scapulothoracic joints. Numerous studies have was to investigate this effect, to help prevent the occur-
shown that the coordinated functioning of these joints is rence of throwing injuries, using the electromagnetic
important for the prevention of shoulder injuries [7,8]. tracking device ’Liberty’. Our hypotheses were as fol-
In MER, the scapulothoracic joint motions are carried lows: 1) restricting thoracic expansion would decrease
out by external rotation, upward rotation, and poste- scapulothoracic external rotation, upward rotation, and
rior tilt in the horizontal, frontal, and sagittal planes, posterior tilt angles and increase glenohumeral external
respectively [9]. These three-axes scapulothoracic joint rotation angle at MER compared with the same move-
motions can be measured using electromagnetic track- ment without restriction, and 2) there would be a posi-
ing devices such as the Polhemus Liberty system (Pol- tive correlation between the decrease in scapulothoracic
hemus, Inc., Colchester, VT, USA). According to the joint angles and the increase in glenohumeral external
Liberty User’s manual, the accuracy of this device is rotation angle.
reported to be 0.8 mm and 0.15◦ for position and ori-
entation, respectively. Currently, it is considered to be
the most useful measurement method for scapulotho- 2. Materials and methods
racic joint motion. A previous study investigating the
relationship between the glenohumeral external rota- 2.1. Study design and setting
tion and the scapulothoracic posterior tilt angles during
MER reported that of 145◦ of MER angle, the gleno- This cross-sectional study examined the kinematic
humeral external rotation angle was 105◦ and the scapu- changes in the scapulothoracic and glenohumeral joints
lothoracic posterior tilt angle was 25◦ [10]. In MER, during shoulder external rotation with and without re-
repetitive impingement between the greater tuberosity stricted thoracic expansion using an electromagnetic
and the glenoid fossa [11] can lead to rotator cuff in- device, Liberty. The study was conducted in a labo-
juries and other shoulder joint diseases [12]. In the up- ratory, and healthy males were recruited. All depen-
per extremity elevation motion on the scapular plane of dent variables of scapulothoracic internal rotation angle,
the injured shoulder, scapulothoracic internal rotation upward rotation angle, posterior tilt angle, and gleno-
is increased and upward rotation and posterior tilt are humeral external rotation angle were compared in each
decreased [13]. When this relationship is disrupted, and participant.
the rate of the MER angle, that is accounted for by the
glenohumeral external rotation, increases, the stress on 2.2. Participants
the shoulder joint increases, which may in turn increase
the risk of occurrence of throwing injuries [14]. Eighteen right-handed healthy males (mean ± SD:
The scapula is in contact with the posterior wall of age, 21.9 ± 1.8 years; height, 171.7 ± 4.4 cm; weight,
the thorax and moves along this wall when perform- 63.0 ± 5.9 kg; body mass index, 21.4 ± 2.0 kg/m2 )
ing movement of the scapulothoracic joint. Therefore, participated in this study. The inclusion criteria were
the scapulothoracic joint movement is determined by as follows: 1) no complaints of shoulder joint pain on
changes in the configuration of the thorax. A study ana- the measurement day, 2) > 90◦ of passive shoulder
lyzing the shoulder flexion angle, scapulothoracic pos- abduction range of motion, and 3) > 75◦ of passive
terior tilt angle, and glenohumeral flexion angle during shoulder external rotation range of motion at 90◦ shoul-
upper limb elevation with limited thoracic expansion der abduction. The exclusion criteria were as follows:
movement stated that the shoulder flexion and scapu- 1) history of upper extremity injury or surgery within
lothoracic posterior tilt angles decreased and the me- the past one year that would affect shoulder motion,
chanical stress on the glenohumeral joint relatively in- 2) history of neurological disorders that would affect
creased [15]. Thus, restriction of thoracic expansion shoulder motion, such as suprascapular nerve palsy, and
motion might decrease scapulothoracic joint motion 3) presence of a lung disease or a restrictive respira-
and produce excessive glenohumeral joint motion for tory condition such as asthma. The inclusion and exclu-
compensation. sion criteria were in accordance with those of previous
However, to the best of our knowledge, none of the studies [16,17].
studies used Liberty to investigate how restriction of The sample size was calculated using G*power
thoracic expansion causes kinematic changes in the 3.1.9.4 software (Heinrich-Heine-University Düssel-
scapulothoracic and glenohumeral joint motions during dorf, Düsseldorf, Germany). The effect size, mean
shoulder external rotation. The purpose of this study power, and alpha error were set to 0.25, 0.80, and 0.05,
 M. Yoshimi et al. / Effect of thoracic expansion restriction on scapulothoracic and glenohumeral joint motion 1401

Fig. 1. Participants sat on the chair with their hip and knee joint flexed Fig. 2. (a) Without restriction, (b) With restriction. One round of
at 90◦ . (a) The start position was set at 90◦ of abduction and 75◦ non-elastic tape was applied to the thorax in the maximal expiratory
external rotation, and (b) the shoulder was externally rotated until state without applying tension. In addition, an elastic was applied
MER in a second. over the non-stretch tape in the same manner for reinforcement. The
tape was applied at the 5th and 10th rib positions.
respectively. The analysis revealed that at least 15 par-
ticipants would make an acceptable sample size. metronome was set to 60 beats per minute and the shoul-
This study was approved by the Ethical Committee der external rotation from the starting position (75◦ of
for Epidemiology of Hiroshima University (E-2177), external rotation) to the MER angle was performed in
and written informed consent was obtained from all par- a second (Fig. 1b). After the participants had practiced
ticipants in accordance with the Declaration of Helsinki. sufficiently, five trials were conducted in each condi-
tion. The trial was started after the examiner confirmed
2.3. Procedures that no scapular elevation or shoulder horizontal abduc-
tion occurred during practice. The order of trials was
The participants performed shoulder external rota- randomized for each participant, with a rest period of
tion in two conditions: with and without restriction of at least one hour between trials.
the thorax by taping. Participants sat on a chair with the
hip and knee joints flexed at 90◦ and the right shoulder 2.4. Measurement of kinematic data
joint abducted at 90◦ . The starting position of shoulder
external rotation by a metal plate was set at 75◦ [17] Kinematic data were measured using an electro-
(Fig. 1a). In accordance with a previous study, the tho- magnetic tracking device, LibertyTM (Polhemus, Inc.,
rax expansion movement was restricted using two types Colchester, VT, USA). The sampling frequency was
of tapes: non-elastic and elastic tapes [15] (Fig. 2). First, 240 Hz. Sensors were attached on the sternum, sacrum,
a 38 mm wide non-elastic tape (CB tape, Nitoms, Inc., bilateral acromion, bilateral humerus, and bilateral fore-
Tokyo, Japan) was applied without tension to the thorax arm. Segmental models composed of thorax, pelvis,
in the maximal expiratory state. In addition, a 50 smm scapula, and humerus were defined [19]. The elec-
wide elastic tape (EB tape, Nitoms, Inc., Tokyo, Japan) tronic unit determined the three-dimensional position
was applied over the non-elastic tape in the same man- and orientation of these sensors within the electro-
ner as reinforcement. The tape was applied at the 5th magnetic field. Each segment was defined by digitized
and 10th rib positions, where the thoracic motion could body landmarks in accordance with the definition of
be restricted without interfering with the scapula. A pre- a joint coordinate system as proposed by the Interna-
vious study showed that restrictions at these positions tional Society of Biomechanics [20]. The sternal notch
limit the thoracic expansion during inspiration [18]. In (SN), xiphoid process (XP), seventh cervical vertebrae
this study, we also measured the circumference of the (C7), and eighth thoracic vertebrae (Th8) were used
thorax during maximal inspiration and maximal expira- as anatomical markers to determine the position and
tion and calculated the difference to confirm the degree orientation of the thorax. The bilateral anterior supe-
of restriction of thoracic expansion. All the tapes were rior iliac spines (ASISR , ASISL ) and pubic symphysis
applied by the same examiner who had at least three (PS) were used as markers to determine the position
years of experience as a physical therapist and who and orientation of the pelvis. Bilateral acromial angles
routinely performed taping. (AAR , AAL ), medial borders (SPR , SPL ), and inferior
In each condition, the participants performed shoul- angles of scapula (IAR , IAL ) were used as markers to
der external rotation while grasping a 500 mL plastic determine the position and orientation of the scapula.
water bottle with the right hand [17]. The electronic The bilateral medial (MER , MEL ) and lateral (LER ,
1402 M. Yoshimi et al. / Effect of thoracic expansion restriction on scapulothoracic and glenohumeral joint motion

Fig. 3. SN: sternal notch, XP: xiphoid process, ASIS: anterior superior
iliac spine, PS: pubic symphysis, AA: acromial angle, SP: medial
border of the scapular spine, IA: inferior angle, HH: humeral head,
ME: medial epicondyle, LE: lateral epicondyle.

LEL ) epicondyles were used to determine the position

and orientation of the humerus. The central position
of the glenohumeral joint was estimated by calculating
the central axis of the rotational motion of the arm [21] Fig. 4. ST: scapulothoracic joint, GH: glenohumeral joint.
(Fig. 3).
analyses. The Shapiro-Wilk test was used to check the
2.5. Data analysis normality of the data. Since normality could not be ob-
tained for the data, a Wilcoxon signed-rank test was
The joint kinematic data were calculated and repre- used to compare the difference in thoracic expansion
sented by the Euler angles based on relative orientations and kinematic data in the two conditions. Effect √ size
of the thorax, scapula, and humerus. The motion of the (r) was calculated using the formula r = Z/ N and
scapula relative to that of the thorax (scapulothoracic defined as follows: small for r > 0.10, medium for r >
joint) was classified as internal (+) or external (-) rota- 0.30, and large for r > 0.50 [22]. Additionally, for the
tion, downward (+) or upward (-) rotation, and poste- scapulothoracic and glenohumeral joint variables, the
rior (+) or anterior (-) tilt (Fig. 4). The motion of the difference between with and without restriction condi-
humerus relative to the scapula (glenohumeral joint) tions for displacements of ER75◦ and MER (displace-
was classified as horizontal adduction (+) or abduction ment in the “with restriction condition” – displacement
(-), elevation (-), and internal (+) or external (-) rotation in the “without restriction condition”), was calculated.
(Fig. 4). Since the Shapiro-Wilk test was not significant, Spear-
The internal rotation, upward rotation, and posterior man’s rank correlation coefficient was calculated to ex-
tilt angles of the scapulothoracic joint, and the external amine the relationship between the variables. The in-
rotation angle of the glenohumeral joint were measured tensity of Pearson’s correlation coefficient was defined
at two time points: 75◦ of external rotation (ER 75◦ ) as small for values from 0.20 to 0.40, medium for 0.40
and at MER angle. In this study, the MER angle was to 0.70, and large for 0.70 to 1.0. The significance level
defined as the maximum external rotation angle of the was set at P < 0.05.
humerothoracic joint. The humerothoracic joint motion
was defined as the motion of the humerus relative to
that of the thorax. The difference between each variable 3. Results
of ER 75◦ and MER was calculated to examine the
angular displacement. For both the variables, the mean 3.1. Difference in thoracic expansion
of three trials, excluding the maximum and minimum
values, was used during data analysis. Table 1 shows the results of the difference in thorax
expansion. With restriction, a significant decrease was
2.6. Statistical analysis observed in both the 5th and the 10th rib positions, com-
pared to conditions without restriction (5th rib position:
IBM SPSS Statistics version 27.0 for Windows (IBM P < 0.001, r = 0.93; 10th rib position: P < 0.001,
Corp., Armonk, NY, USA) was used for all statistical r = 0.91).
 M. Yoshimi et al. / Effect of thoracic expansion restriction on scapulothoracic and glenohumeral joint motion 1403

Table 1
Difference in thoracic expansion
Values Without restriction With restriction P value Effect size
Mean ± SD 95% CI Mean ± SD 95% CI
Lower Upper Lower Upper
5th rib position (cm) 5.1 ± 1.4 4.4 5.8 2.1 ± 0.9 1.6 2.5 < 0.001* 0.93
10th rib position (cm) 5.6 ± 2.0 4.5 6.6 1.9 ± 0.8 1.5 2.3 < 0.001* 0.91
SD: standard deviation, CI: confidence interval. *Significant difference between with and without restriction (P < 0.05).

Fig. 5. The difference between the displacement with and without restriction was calculated. Spearman’s rank correlation coefficient was used to
determine the relationships. A positive displacement of ST posterior tilt indicates posterior tilt and a negative indicates an anterior tilt. On the
other hand, positive displacement of GH internal rotation indicates internal rotation, while negative displacement indicates external rotation. A
significant positive correlation was observed (P < 0.05).

3.2. Kinematic data joint motions during shoulder external rotation. It was
revealed that restriction of thoracic expansion decreased
Table 2 shows the results of the kinematic data of the the scapulothoracic posterior tilt angle and increased the
scapulothoracic and glenohumeral joints between the glenohumeral external rotation angle in MER. However,
two conditions. Significant differences were observed no significant change was observed at MER angle with
in scapulothoracic posterior tilt (P = 0.047, r = 0.50) or without restriction of thoracic expansion. Therefore,
and glenohumeral external rotation (P = 0.005, r = increase in glenohumeral external rotation is a com-
0.67) at MER, and there were significant differences in pensatory movement for the decrease in scapulotho-
the displacement of scapulothoracic posterior tilt (P = racic posterior tilt associated with restricted thoracic
0.001, r = 0.74) and displacement of glenohumeral expansion.
external rotation (P = 0.006, r = 0.66). On the other As reported previously, the present study also ob-
hand, no significant differences occurred in scapulotho- served restricted thoracic expansion during maximal
racic internal rotation and upward rotation angles in
expiration and maximal inspiration. Thoracic expansion
terms of both angle at MER and displacement.
occurs by rotational movements around the costover-
Figure 5 shows the relationship between the differ-
tebral joints that occur antero-posteriorly in the upper
ence in displacement of the scapulothoracic and the
thorax and medio-laterally in the lower thorax [23]. In
glenohumeral joints and the presence of restriction. A
the middle of the thorax, the axis of the costoverte-
significant positive correlation existed between the pos-
terior tilt of the scapulothoracic joint and the internal bral joint is at 45◦ angle [24], so that the thoracic ex-
rotation of the glenohumeral joint with a correlation pansion motion occurs equally in the anterior-posterior
coefficient of 0.54 (P = 0.021). and medial-lateral directions. Therefore, the restriction
of motion, especially in the medial-lateral direction, is
considered to have resulted in a restriction of 3.0 cm in
4. Discussion the 5th rib position and 3.7 cm in the 10th rib position.
The scapulothoracic posterior tilt angle in the re-
This study aimed to clarify the effect of restricted tho- stricted condition in MER was significantly lower than
racic expansion on scapulothoracic and glenohumeral that in the unrestricted condition. Previous studies
1404 M. Yoshimi et al. / Effect of thoracic expansion restriction on scapulothoracic and glenohumeral joint motion

Table 2
Kinematic data of scapulothoracic and glenohumeral motions with and without restriction
Values Without restriction With restriction
Mean ± SD 95% CI Mean ± SD 95% CI P value Effect size
Lower Upper Lower Upper
MER (deg) 103.4 ± 10.8 97.4 109.4 106.1 ± 9.7 100.7 111.5 0.162 0.37
ST Internal Rotation (deg)
ER 75◦ 15.0 ± 8.6 10.2 19.8 16.5 ± 9.8 11.0 21.9 0.241 0.31
MER 7.6 ± 10.1 2.0 13.2 9.4 ± 9.8 4.0 14.8 0.106 0.42
Displacement −7.4 ± 3.6 −9.4 −5.4 −7.1 ± 4.0 −9.3 −4.9 0.627 0.13
ST Downward Rotation (deg)
ER 75◦ −21.6 ± 5.5 −24.7 −18.6 −21.1 ± 6.6 −24.8 −17.4 0.485 0.19
MER −26.3 ± 6.2 −29.7 −22.8 −26.1 ± 7.4 −30.1 −22.0 0.805 0.07
Displacement −4.7 ± 2.6 −6.1 −3.2 −5.0 ± 3.4 −6.9 −3.1 0.820 0.04
ST Posterior Tilt (deg)
ER 75◦ 13.2 ± 9.9 7.7 18.7 9.6 ± 12.5 2.7 16.5 0.217 0.33
MER 21.4 ± 10.6 15.5 27.2 15.5 ± 14.4 7.5 23.4 0.047* 0.50
Displacement 8.2 ± 3.8 6.1 10.3 5.8 ± 4.1 3.6 8.1 0.001* 0.74
GH Internal Rotation (deg)
ER 75◦ −41.5 ± 24.4 −55.0 −28.0 −47.6 ± 23.7 −60.7 −34.5 0.073 0.46
MER −64.5 ± 28.0 −80.0 −49.0 −76.3 ± 30.1 −93.0 −59.6 0.005* 0.67
Displacement −23.0 ± 10.0 −28.5 −17.4 −28.7 ± 11.8 −35.3 −22.2 0.006* 0.66
SD: standard deviation, CI: confidence interval, MER: maximum external rotation, ST: scapulothoracic joint, GH: glenohumeral joint, ER 75◦ :
75◦ of external rotation. *Significant difference between with and without restriction (P < 0.05).

showed that changes in the configuration of the thorax is possible that the glenohumeral movement was in-
were a factor in the restriction of the scapulothoracic creased more to prevent the decrease in shoulder exter-
joint. The thoracic extension motion is considered to nal rotation. These results indicate that MER angle was
be the cause of this change in thoracic configuration. not altered by limitation of thoracic extension, but ST
Backward rotational movement of the ribs by the cos- posterior tilt was increased and GH external rotation
tovertebral joint is caused by extension of the thoracic was decreased.
spine, especially the lower thoracic spine [25]. As the One throwing injury caused by excessive gleno-
thorax expands, it is elevated superiorly and anteriorly, humeral external rotation is shoulder internal impinge-
and its posterior wall tilts backward. In this study, tap- ment [11]. This is characterized by contact between
ing the thorax could have possibly decreased the pos- the greater tuberosity of the humerus and the glenoid
terior tilt of the scapulothoracic joint by limiting these fossa during the late cocking phase and early accelera-
movements. tion phase, when the shoulder exhibits abduction and
The most important finding of this study was that external rotation, and most athletes with internal im-
there was no significant difference in MER angle be- pingement complain of pain in the posterior shoulder
tween conditions, despite the restricted scapulothoracic joint [27,28]. Previous studies have shown that the nar-
joint motion. A previous study reported that a decrease rowing of the distance between the glenoid fossa and
in scapulothoracic joint motion resulted in a decrease in the humeral head due to restricted scapulothoracic mo-
MER angle [17]. However, in the present study, MER tion and excessive glenohumeral motion is a factor in
angle did not change with restriction. This was because the development of shoulder internal impingement [29].
the excessive glenohumeral external rotation compen- These findings suggest that restriction of thoracic ex-
sated for the decreased motion of the scapulothoracic pansion is a risk factor for the development of shoulder
joint, as shown in the results of the moderate correlation internal impingement, as it may cause narrowing of the
between displacement of the scapulothoracic posterior shoulder joint distance due to excessive glenohumeral
tilt and displacement of the glenohumeral internal ro- external rotation. Improving scapulothoracic joint func-
tation. It is obvious that the coordinated movement of tion by strengthening the middle and lower trapezius is
the scapulothoracic and glenohumeral joints is essen- used for rehabilitation for throwing injuries [30]. How-
tial for shoulder movement. It has been reported that ever, the findings of the present study indicate that tho-
malfunctioning of one of the joints directly affected the racic expansion are essential for improving scapulotho-
other joint [26]. Thoracic expansion was reduced and racic joint function and that thoracic exercises should
scapulothoracic joint motion was limited. However, it also be focused on the rehabilitation of throwing in-
 M. Yoshimi et al. / Effect of thoracic expansion restriction on scapulothoracic and glenohumeral joint motion 1405

juries. Future research including people with restricted Funding

thoracic expansion is warranted to clarify the causal
relationship with shoulder internal impingement. This research did not receive any specific grant from
This study had several limitations. First, the restric- funding agencies in the public, commercial, or not-for-
tion of thoracic expansion was done manually by the profit sectors.
same examiner by taping. Therefore, skin movement
could possibly have influenced the measurements. Sec-
ond, the participants were young healthy adult males. References
The elevation motion in patients with shoulder joint dis-
ease may differ from that in healthy individuals. More- [1] Erickson BJ, Chalmers PN, Axe MJ, Romeo AA. Exceed-
over, the static alignment in overhead athletes may be ing pitch count recommendations in little league baseball in-
adapted to competition-specific movements. Thus, there creases the chance of requiring tommy john surgery as a pro-
fessional baseball pitcher. Orthop J Sports Med. 2017; 5(3).
is a need to investigate patients with shoulder joint dis-
doi: 10.1177/2325967117695085.
eases and overhead athletes in the future. Finally, this [2] Norton R, Honstad C, Joshi R, Silvis M, Chinchilli V, Dhawan
study was conducted in the sitting position, so it is not A. Risk factors for elbow and shoulder injuries in adolescent
clear whether the results would be similar during ac- baseball players: a systematic review. Am J Sports Med. 2019;
tual pitching motion. For detailed clarification of the 47(4): 982-990. doi: 10.1177/0363546518760573.
[3] Fleisig GS, Andrews JR, Cutter GR, Weber A, Loftice J,
effect of restricted thoracic expansion on throwing mo- McMichael C, et al. Risk of serious injury for young baseball
tion, future studies should investigate scapulothoracic pitchers: a 10-year prospective study. Am J Sports Med. 2011;
and glenohumeral joints motion during actual throwing 39(2): 253-257. doi: 10.1177/0363546510384224.
motion. [4] Freehill MT, Mannava S, Higgins LD, Lädermann A, Stone
AV. Thrower’s exostosis of the shoulder: a systematic review
with a novel classification. Orthop J Sports Med. 2020; 8(7).
doi: 10.1177/2325967120932101.
5. Conclusion [5] Jobe FW, Tibone JE, Perry J, Moynes D. An EMG analysis of
the shoulder in throwing and pitching. A preliminary report.
This study investigated the effects of thoracic expan- Am J Sports Med. 1983; 11(1): 3-5. doi: 10.1177/0363546583
01100102.
sion restriction on scapulothoracic and glenohumeral
[6] Fleisig GS, Andrews JR, Dillman CJ, Escamilla RF. Kinetics
joint motions during shoulder external rotation in a sit- of baseball pitching with implications about injury mecha-
ting position assuming MER. Restriction of thoracic nisms. Am J Sports Med. 1995; 23(2): 233-239. doi: 10.1177/
expansion motion decreased the scapulothoracic pos- 036354659502300218.
terior tilt and increased the glenohumeral external ro- [7] Kolz CW, Sulkar HJ, Aliaj K, Tashjian RZ, Chalmers PN, Qiu
Y, et al. Age-related differences in humerothoracic, scapu-
tation, suggesting that restriction of thoracic expan- lothoracic, and glenohumeral kinematics during elevation
sion increases mechanical stress on the glenohumeral and rotation motions. J Biomech. 2021; 117. doi: 10.1016/j.
joint. The results indicate that it is necessary to focus jbiomech.2021.110266.
on thoracic expansion exercises as the foundation for [8] Kibler WB, Thomas SJ. Pathomechanics of the throwing
shoulder. Sports Med Arthrosc Rev. 2012; 20(1): 22-29. doi:
interventions to improve scapulothoracic joint motion, 10.1097/JSA.0b013e3182432cf2.
such as scapular mobilization and periscapular muscle [9] Karduna AR, McClure PW, Michener LA, Sennett B. Dynamic
exercises. Emphasis on thoracic extension movement measurements of three-dimensional scapular kinematics: a
during shoulder joint exercises may reduce the stress on validation study. J Biomech Eng. 2001; 123(2): 184-190. doi:
10.1115/1.1351892.
the glenohumeral joint and contribute to the prevention [10] Miyashita K, Kobayashi H, Koshida S, Urabe Y. Gleno-
of pitching disorders. humeral, scapular, and thoracic angles at maximum shoulder
external rotation in throwing. Am J Sports Med. 2010; 38(2):
363-368. doi: 10.1177/0363546509347542.
Acknowledgments [11] Walch G, Boileau P, Noel E, Donell ST. Impingement of the
deep surface of the supraspinatus tendon on the posterosuperior
glenoid rim: An arthroscopic study. J Shoulder Elbow Surg.
The authors would like to thank everyone who par- 1992; 1(5): 238-245. doi: 10.1016/S1058-2746(09)80065-7.
ticipated in this study. [12] Takahashi M, Iwamoto K, Monma M, Mutsuzaki H, Mizukami
M. The area of impingement in the throwing versus nonthrow-
ing shoulder of collegiate baseball players: an MRI study of
the simulated late-cocking phase of throwing. Orthop J Sports
Conflict of interest
Med. 2021; 9(3). doi: 10.1177/2325967121992133.
[13] Ludewig PM, Reynolds JF. The association of scapular kine-
The authors have no conflict of interest relevant to matics and glenohumeral joint pathologies. J Orthop Sports
this article. Phys Ther. 2009; 39(2): 90-104. doi: 10.2519/jospt.2009.2808.
1406 M. Yoshimi et al. / Effect of thoracic expansion restriction on scapulothoracic and glenohumeral joint motion

[14] Kibler WB, Ludewig PM, McClure PW, Michener LA, Bak [22] Cohen J. Statistical power analysis for behavioral sciences.
K, Sciascia AD. Clinical implications of scapular dyskinesis 2nd ed., Hillsdale: Lawrence Erlbaum Associates, 1988.
in shoulder injury: the 2013 consensus statement from the [23] Bastir M, García-Martínez D, Torres-Tamayo N, Sanchis-
’Scapular Summit’. Br J Sports Med. 2013; 47(14): 877-885. Gimeno JA, O’Higgins P, Utrilla C, et al. In vivo 3D analy-
doi: 10.1136/bjsports-2013-092425. sis of thoracic kinematics: changes in size and shape during
[15] Okamune R, Miyashita K, Koyama T, Tani Y, Ota K, Emon breathing and their implications for respiratory function in re-
Y, et al. A three-dimensional motion analysis of anterior upper cent humans and fossil hominins. Anat Rec (Hoboken). 2017;
limb elevation with thoracic motion restriction. Rigakuryoho 300(2): 255-264. doi: 10.1002/ar.23503.
Kagaku 2020; 35(2): 217-222. doi: 10.1589/rika.35.217. [24] Beyer B, Sholukha V, Dugailly PM, Rooze M, Moiseev F,
[16] Konda S, Yanai T, Sakurai S. Scapular rotation to attain the Feipel V, et al. In vivo thorax 3D modelling from costoverte-
peak shoulder external rotation in tennis serve. Med Sci Sports bral joint complex kinematics. Clin Biomech (Bristol, Avon).
Exerc. 2010; 42(9): 1745-1753. doi: 10.1249/MSS.0b013e31 2014; 29(4): 434-438. doi: 10.1016/j.clinbiomech.2014.01.
81d64103. 007.
[17] Suzuki Y, Muraki T, Sekiguchi Y, Ishikawa H, Yaguchi H, [25] Masharawi Y, Rothschild B, Dar G, Peleg S, Robinson
Suzuki Y, et al. Influence of thoracic posture on scapulotho- D, Been E, et al. Facet orientation in the thoracolumbar
racic and glenohumeral motions during eccentric shoulder ex- spine: three-dimensional anatomic and biomechanical analysis.
ternal rotation. Gait Posture. 2019; 67: 207-212. doi: 10.1016/j. Spine. 2004; 29(16): 1755-1763. doi: 10.1097/01.brs.0000134
gaitpost.2018.10.022. 575.04084.ef.
[18] Okamune R, Miyashita K, Tani Y, Ota K, Emon Y, Koyama [26] Paine R, Voight ML. The role of the scapula. Int J Sports Phys
T, et al. A comparison of movements of the thoracic cage Ther. 2013; 8(5): 617-629.
when inspiring with thoracic expansion restrictions at different [27] Bolia IK, Collon K, Bogdanov J, Lan R, Petrigliano FA. Man-
levels. Rigakuryoho Kagaku 2019; 34(1): 21-25. doi: 10.1589/ agement options for shoulder impingement syndrome in ath-
rika.34.21. letes: insights and future directions. Open Access J Sports
[19] Kono Y, Sakamitsu T, Sasadai J, Yamamoto M, Okamoto K, Med. 2021; 12: 43-53. doi: 10.2147/OAJSM.S281100.
Ushio K, et al. The comparison of biomechanics of kayak pad- [28] Corpus KT, Camp CL, Dines DM, Altchek DW, Dines JS.
dling between para-kayakers and elite able-bodied kayakers: a Evaluation and treatment of internal impingement of the shoul-
pilot study. Sport Sci Health. 2021; 17(4): 947-951. doi: 10. der in overhead athletes. World J Orthop. 2016; 7(12): 776-784.
1007/s11332-021-00757-4. doi: 10.5312/wjo.v7.i12.776.
[20] Wu G, van der Helm FC, Veeger HE, Makhsous M, Van Roy [29] Mihata T, Jun BJ, Bui CN, Hwang J, McGarry MH, Kinoshita
P, Anglin C, et al. ISB recommendation on definitions of M, et al. Effect of scapular orientation on shoulder internal
joint coordinate systems of various joints for the reporting of impingement in a cadaveric model of the cocking phase of
human joint motion-Part II: shoulder, elbow, wrist and hand. throwing. J Bone Joint Surg Am. 2012; 94(17): 1576-1583.
J Biomech. 2005; 38(5): 981-992. doi: 10.1016/j.jbiomech. doi: 10.2106/JBJS.J.01972.
2004.05.042. [30] Mayes M, Salesky M, Lansdown DA. Throwing injury preven-
[21] Veeger HE. The position of the rotation center of the gleno- tion strategies with a whole kinetic chain-focused approach.
humeral joint. J Biomech. 2000; 33(12): 1711-1715. doi: 10. Curr Rev Musculoskelet Med. 2022; 1-12. doi: 10.1007/s12178
1016/s0021-9290(00)00141-x. -022-09744-9.