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THE AMERICAN JOURNAL OF SPORTS MEDICINE, Vol. 26, No. 2
© 1998 American Orthopaedic Society for Sports Medicine
Current Concepts
The Role of the Scapula in Athletic
Shoulder Function
W. Ben Kibler,* MD
ABSTRACT muscles attach to the scapula (Fig. 1). The first group
includes the trapezius, rhomboid, levator scapulae, and
The exact role and the function of the scapula are the serratus anterior muscles, and is concerned with sta-
misunderstood in many clinical situations. This lack of bilization and rotation of the scapula. The second group
awareness often translates into incomplete evaluation includes the extrinsic muscles of the shoulder joint—the
and diagnosis of shoulder problems. In addition, scap- deltoid, biceps, and triceps muscles. The final group in-
ular rehabilitation is often ignored. Recent research, cludes the intrinsic muscles of the rotator cuff—the sub-
however, has demonstrated a pivotal role for the scap- scapularis, the supraspinatus, infraspinatus, and teres
ula in shoulder function, shoulder injury, and shoulder minor muscles. All of the groups have different actions in
rehabilitation. This knowledge will help the physician to both shoulder function and shoulder injury and need to be
provide more comprehensive care for the athlete. This understood in light of these separate actions.
“Current Concepts” review will address the anatomy of
the scapula, the roles that the scapula plays in over-
head throwing and serving activities, the normal bio-
THE ROLES OF THE SCAPULA IN OVERHEAD
mechanics of the scapula, abnormal biomechanics and
THROWING AND SERVING ACTIVITIES
physiology of the scapula, how the scapula may func-
tion in injuries that occur around the shoulder, and The roles of the scapula in throwing and serving are
treatment and rehabilitation of scapular problems. concerned with achieving appropriate motions and posi-
tions to facilitate shoulder function. Optimal function is
achieved when normal anatomy interacts with normal
ANATOMY physiology to create normal biomechanics. The scapula’s
various roles are concerned with achieving these motions
The scapula is a flat blade lying along the thoracic wall. and positions to facilitate the efficient physiology and
Its wide, thin configuration allows for smooth gliding of biomechanics to allow optimum shoulder function. The
the scapula on the thoracic wall and provides a large failure of the scapula to perform these roles causes ineffi-
surface area for muscle attachments both distally and cient physiology and biomechanics and, therefore, ineffi-
proximally. Stabilization of the scapula is rather tenuous. cient shoulder function. This can cause poor performance,
It is attached to the axial skeleton by the strut of the and can cause or exacerbate shoulder injury.
clavicle and stabilized onto the chest wall by the muscle The first role of the scapula is to be a stable part of the
attachments to the spinous processes and the ribs. The glenohumeral articulation. The glenoid is the socket of the
strut configuration allows a degree of stabilization against ball-and-socket arrangement of the glenohumeral joint. To
medially directed forces but allows a large amount of maintain the ball-and-socket configuration, the scapula
scapular rotation and translation that is then controlled must move in a coordinated relationship with the moving
by the dynamic action of the muscles. Three groups of humerus so that the instant center of rotation—the math-
ematical point within the humeral head that defines the
axis of rotation of the glenohumeral joint—is constrained
* Address correspondence and reprint requests to W. Ben Kibler, MD, within a physiologic pattern throughout the full range of
Lexington Clinic Sports Medicine Center, 1221 South Broadway, Lexington, shoulder motion in throwing or serving.21
KY 40504.
Neither the author nor his related institution received financial benefit from The coordinated movements also keep the angle be-
research in this study. tween the glenoid and the humerus within a physiologi-
325
326 Kibler American Journal of Sports Medicine
cally tolerable range. This “safe zone” of glenohumeral most appropriate shoulder function.5, 7, 12, 14 For most
activity falls roughly within 30° of extension or flexion shoulder activities, this sequencing starts at the ground.
from the neutral position in the scapular plane.24 This The individual body segments, or links, are coordinated in
safe zone and stable constrained center of rotation allow their movements by muscle activity and body positions to
“concavity/compression” of the glenohumeral joint to be generate, summate, and transfer force through these seg-
maximal. Concavity/compression is the result of intraar- ments to the terminal link (Fig. 1). This sequencing is
ticular pressure, positioning of the glenoid in relationship usually termed the “kinetic chain.”
to the humerus, and muscle activity acting in concert to The largest proportion of kinetic energy and force in this
maintain the ball-and-socket kinematics.21 Proper align- sequencing is derived from the larger proximal body seg-
ment of the glenoid allows the optimum function of the ments.14 Studies have shown that 51% of the total kinetic
bony constraints to glenohumeral motion and allows the energy and 54% of the total force generated in the tennis
most efficient position of the intrinsic muscles of the rota- serve are created by the lower legs, hip, and trunk.14
tor cuff to allow compression into the glenoid socket, The scapula is pivotal in transferring the large forces
thereby enhancing the muscular constraint systems and high energy from the major source for force and en-
around the shoulder as well.24 ergy—the legs, back, and trunk—to the actual delivery
The second role of the scapula is retraction and protrac- mechanism of the energy and force—the arm and the
tion along the thoracic wall. The scapula needs to retract hand.5, 12, 14, 19 Forces that are generated in the proximal
to facilitate the position of cocking for such activities as segments have to be transferred efficiently and must be
the baseball throw, the tennis serve, or the swimming regulated as they go through the funnel of the shoulder.
recovery. Efficient achievement of this cocking position This can be accomplished most efficiently through the
allows for retensioning of the anterior muscular struc- stable and controlled platform of the scapula. The entire
tures and efficient change of muscle phase of contraction arm rotates as a unit around the stable base of the gleno-
from eccentric to concentric on the anterior muscles and humeral socket. In many tennis serving motions, the feet
concentric to eccentric function on the posterior mus- and body are actually off the ground when this rotation
cles.7, 24 This position has been called the “full tank of reaches its maximum peak. The entire stable base of the
energy” position because it allows the explosive phase of arm, in this situation, rests on the scapula rather than on
acceleration in throwing or serving. As acceleration pro-
ceeds, the scapula must protract in a smooth fashion lat-
erally and then anteriorly around the thoracic wall to
allow the scapula to maintain a normal position in rela-
tionship to the humerus and also to dissipate some of the
deceleration forces that occur in follow-through as the arm
goes forward.24
The third role that the scapula plays in the throwing
and serving motion is elevation of the acromion. The scap-
ula must rotate in the cocking and acceleration phases to
clear the acromion from the rotator cuff to decrease im-
pingement and coracoacromial arch compression. Almost
all throwing and serving activities occur with a humerus-
to-spine angle of between 85° and 100° of abduction.7
Therefore, the acromion must be tilted up to avoid imping-
ing the rotator cuff in this position.
The fourth role that the scapula plays is as a base for
muscle attachment. The scapular stabilizers attach to the
medial, superior, and inferior borders of the scapula and
control the motion and position of the scapula to allow it to
accomplish all of its roles. The extrinsic muscles—the
deltoid, biceps, and triceps—attach along the lateral as-
pect of the scapula, perform gross motor activities of the
glenohumeral joint, and form the second cone of Saha.28
The intrinsic muscles of the rotator cuff attach along the
entire surface of the scapula and are aligned so that their
most efficient activity, working concentrically or eccentri-
cally in a straight line, occurs with the arm between 70°
and 100° of abduction.24 In this fashion, they are biome-
chanically considered to be a “compressor cuff” to com-
press the humeral head into the socket. Figure 1. Link sequencing allows efficient generation, sum-
The final role that the scapula plays in shoulder func- mation, and transfer of kinetic energy and force from the
tion is that of being a link in the proximal-to-distal se- base of support, usually the ground, to the terminal link,
quencing of velocity, energy, and forces that allows the usually the hand.
Vol. 26, No. 2, 1998 The Scapula in Athletic Shoulder Function 327
the feet or the ground. Therefore, stability of the scapula ABNORMAL BIOMECHANICS AND PHYSIOLOGY
in relationship to the entire moving arm is the key point at
this important time in the throwing sequence. The scapular roles can be altered by many anatomic fac-
In summary, it may be seen that there are many diverse tors to create abnormal biomechanics and physiology, both
roles that the scapula must play to achieve appropriate locally and in the kinetic chain. The bony anatomy can be
shoulder function. These roles are interrelated and are altered by either body posture or by bony injury. Thoracic
directed toward maintaining the glenohumeral instant kyphosis or neck lordosis can result in excessive protrac-
center of rotation in the normal path and providing a tion of the scapula so that impingement occurs with ele-
stable base for muscular function. vation, and excessive muscular energy will be required to
achieve the proper position of retraction on the thoracic
wall (Fig. 2). Excessive drooping of the shoulder, termed
“tennis shoulder,” can affect the positioning of the scapula,
NORMAL BIOMECHANICS AND PHYSIOLOGY OF once again leading to impingement or problems with mus-
THE SCAPULA cle function. Injuries of the clavicle or scapula can alter
the orientation of the scapula, or the length of the clavic-
Descriptive biomechanics of the scapula reveal that large ular strut of the scapula, or cause painful clinical situa-
rotations and large motions occur in athletic shoulder tions that would inhibit muscle function. Acromioclavicu-
function. In the normal abduction mechanism, the scapula lar joint arthrosis or separation can also lead to
moves laterally in the first 30° to 50° of glenohumeral abnormalities with the strut function of the clavicle and
abduction. As further abduction occurs, the scapula then alter normal kinematics of the scapula.
rotates about a fixed axis through an arc of approximately Most of the abnormal biomechanics and physiology that
65° as the shoulder reaches full elevation.26 This motion occur in injuries seen in a sports medicine setting can be
accounts for the 2:1 ratio between glenohumeral abduc- traced to alterations in the function of the muscles that
tion and scapulothoracic rotation that is observed in most control the scapula.20, 22 Nerve injury either to the long
throwing athletes. Other studies have shown that this thoracic nerve or the spinal accessory nerve can alter
ratio varies between 1:1 and 4:1 depending on the phases muscular function of the serratus anterior or the trapezius
of abduction; however, for the entire abduction motion, the muscle, respectively, to give abnormal stabilization and
approximate 2:1 ratio holds true.12 control. This type of nerve injury occurs in less than 5% of
Translation of the scapula in retraction and protraction the muscle function abnormalities.
occurs around the curvature of the thoracic wall. Depend- More commonly, muscles are either directly injured
ing on the size of the person and the vigorousness of the from direct blow trauma, have microtrauma-induced
throwing activity, this translation may occur over dis- strain in the muscles leading to muscle weakness and
tances of 15 to 18 cm.15 Retraction is mainly in a curvi- force couple imbalance, or are inhibited by painful condi-
linear fashion around the wall, but protraction may pro- tions around the shoulder. Muscle inhibition or weakness
ceed in a slightly upward or downward motion depending is common in glenohumeral abnormalities, whether from
on the position of the arm in the throwing or serving instability, labral lesions, or arthrosis.1, 20, 22, 29 It appears
activity. The motion is a bit more in a superior direction in that the serratus anterior and the lower trapezius muscles
the tennis serve, in which a lot of the acceleration is in a are the most susceptible to the effect of the inhibition, and
superior direction, compared with the baseball throw, in they are involved in early phases of shoulder abnormali-
which most of the acceleration is in an anterior ties.8, 24 Muscle inhibition, and resulting scapular insta-
direction.7, 17 bility, appears to be a nonspecific response to a painful
Descriptive physiology shows that these motions and condition in the shoulder rather than a specific response
translations occur as a result of active muscle firing, in to a certain glenohumeral pathologic situation. This is
addition to passive motion due to the angular accelera- verified by the finding of scapular instability in as many
tions of the trunk and arm. There is a large amount of as 68% of rotator cuff problems and 100% of glenohumeral
muscle activity around the scapula in the scapular stabi- instability problems.20, 30 Inhibition is seen both as a de-
lizers.1, 4, 22 These muscles act mainly as force couples, creased ability for the muscles to exert torque and stabi-
which are muscles that are paired to control the move- lize the scapula and also as a disorganization of the nor-
ment or position of a joint or a body part. The appropriate mal muscle firing patterns of the muscles around the
force couples for scapular stabilization include the upper shoulder.8, 20, 30
and lower portions of the trapezius muscle working to- Glenohumeral inflexibility also can create abnormal
gether with the rhomboid muscles, paired with the serra- biomechanics of the scapula. Posterior shoulder inflexibil-
tus anterior muscle. The appropriate force couples for ity, whether due to capsular or muscular tightness, affects
acromial elevation are the lower trapezius and the serra- the smooth motion of the glenohumeral joint and creates a
tus muscles working together paired with the upper tra- wind-up effect so that the glenoid and scapula actually get
pezius and rhomboid muscles. Muscles are noted to act in pulled in a forward and inferior direction by the moving
different parts of the force couples depending on the ac- arm.7 This may create an excessive amount of protraction
tivity requirements. Each of these specific actions and of the scapula on the thorax due to the obligatory nature of
force couples must be evaluated and rehabilitated with bringing the throwing arm into the horizontally adducted
these different functions in mind.24, 29 position in follow-through. Because of the geometry of the
328 Kibler American Journal of Sports Medicine
Figure 2. Scapular protraction affects arm elevation before impingement. Normal scapular position (A) and motion (B);
abnormal shoulder drooping and scapular protraction (C), and resulting early impingement (D).
Vol. 26, No. 2, 1998 The Scapula in Athletic Shoulder Function 329
upper aspect of the thorax, the more the scapula is pro- traction of the scapula on the thorax would cause loss of a
tracted in follow-through, the farther it and its acromion stable cocking point and lack of ability to explode during
move anteriorly and inferiorly around the thorax. The acceleration out of the full tank of energy position of full
more inferiorly the scapula moves, the less it is able to cocking. Lack of full scapular protraction around the tho-
elevate and avoid impingement. Therefore, in the position racic wall increases the deceleration forces on the shoul-
of acceleration and follow-through, the excessive protrac- der and causes alteration in the normal safe zone relation-
tion may cause decreased clearance and increased risk of ship between the glenoid and the humerus as the arm
rotator cuff impingement because of the abnormal moves through the acceleration phase.4, 7, 24 Too much pro-
biomechanics. traction because of tightness in the glenohumeral capsule
will cause abnormalities of impingement as the scapula
rotates down and forward. These cumulatively lead to
THE ROLE OF THE SCAPULA IN abnormalities in concavity/compression due to the
SHOULDER INJURIES changes in the safe zone of the glenohumeral angle.
Loss of coordinated retraction/protraction in the throw-
The abnormal biomechanics and physiology that can occur ing motion also creates a relative glenoid antetilting or
around the shoulder create abnormal scapular positions functional anteversion, whereby the anterior aspect of the
and motions that decrease normal shoulder function. This glenohumeral joint is more open and the normal anterior
set of abnormal motions and positions has been termed bony buttress to anterior translation is deficient (Fig. 4).
“scapulothoracic dyskinesis,”30 “floating scapula” (F. W. This opening up and lack of bony buttress causes in-
Jobe, personal communication, 1990), or “lateral scapular creased shear stresses on the rest of the anterior stabiliz-
slide”16 by different authors, but basically it denotes the ing structures, the labrum and glenohumeral ligaments,
same phenomenon: the roles of the scapula are not being which further causes increased risk of shear injury or
fulfilled in their normal fashion (Fig. 3). strain.10, 16 This decreases the ability of the glenoid to be
Alterations in retraction and protraction will change the a stable socket for the rotating humerus as the instant
normal parameters for scapular motion. Lack of full re- center of rotation changes.
Lack of appropriate acromial elevation leads to impinge-
ment problems in the cocking and follow-through phases.
This type of impingement is commonly seen not only as
the sole source of impingement but also as a secondary
source of impingement in other shoulder problems, such
as glenohumeral instability.10, 11, 20 The serratus and es-
pecially the lower trapezius muscles appear to be the first
muscles involved in inhibition-based muscle dysfunc-
tion.8, 24 These two muscles form a crucial part of the force
couple responsible for elevating the acromion. Lack of
acromial elevation and consequent secondary impinge-
ment can be seen early in many shoulder problems, such
as rotator cuff tendinitis and glenohumeral instability,
and can play a major role in defining the clinical problems
that are associated with these diagnostic entities.11, 16, 30
Lack of a stable muscular anchor affects all of the func-
tions of the muscles attached to the scapula. Muscles
without a stable base of origin cannot develop appropriate
or maximal torque with a concentric contraction, thereby
decreasing their strength and contributing to problems
not only with strength production but also in muscular
imbalance. If the scapula is truly unstable on the thoracic
wall, as can be seen in spinal accessory nerve palsies or in
extremely inhibited muscles, then an actual reversal of
the origin and insertion occurs, and the distal end of the
muscle becomes the origin. When this phenomenon oc-
curs, the scapula is actually pulled laterally by the muscle,
which would be contracting from the more stable distal
end on the humerus rather than from the proximal end on
the scapula. This phenomenon increases the scapulotho-
racic dyskinesis and lateral scapular slide.
One of the most important abnormalities in abnormal
Figure 3. Scapular dyskinesis: abnormal scapular retraction scapular biomechanics is the loss of the link function in
(winging) (A) and abnormal scapular elevation on arm ele- the kinetic chain (Fig. 1). The kinetic chain is the most
vation (B). efficient system for developing energy and force to be
330 Kibler American Journal of Sports Medicine
Figure 7. Lateral scapular slide measurement. A, the first position, with arms at side; B, the second position, with hands on hips;
C, the third position, with arms at or below 90° abduction, with glenohumeral internal rotation.
measurements from the reference point on the spine to the at or below 90°, the position of impingement is avoided,
medial border of the scapula are measured on both sides. and, therefore, pain-based inhibition of the musculature is
In the second position, the new position of the inferome- less likely to occur. Investigations of this testing proce-
dial border of the scapula is marked, and the reference dure show that in asymptomatic throwing athletes, as the
point on the spine is maintained. The distances once again progression of muscle activity goes from the first to the
are calculated on both sides. The same protocol is done for third position, the amount of asymmetry of the scapular
the third position. positions becomes less, indicating the increasing role of
Tests for reliability and validity of this measuring sys- the scapular stabilizing muscles in controlling the retrac-
tem have been done. Studies on the accuracy of marking tion of the scapula as the arm abducts.
the inferomedial border of the scapula in comparison with In a group of injured patients, this change in symmetry
radiographic evaluation of the same point when marked does not occur, and the degree of asymmetry actually
by a lead shot have shown a correlation of 0.91 with the increases when going from the first to the third position
different positions. Therefore, it does appear that the po- (Table 3). The side-to-side differences in the injured ath-
sition that is marked on the skin does correspond well letes are consistently greater than 0.83 cm, with a range of
with the actual position of the inferomedial border of the 0.83 to 1.75 cm. For purposes of clinical evaluation, we
scapula. Test-retest and intertest reliability has shown have established 1.5 cm asymmetry as the threshold of
that the test-retest (intratester) relationship is between abnormality and accept this in any of the positions, al-
0.84 and 0.88, and that the intertester reliability is be-
tween 0.77 and 0.85 depending on the position (Table 2).23
The third position is the most difficult to measure accu- TABLE 2
rately because of the muscle activity. Even so, this posi- Test-Retest and Intertest Reliability of Lateral
Slide Measurements
tion achieved a test-retest and intertester reliability of
greater than 0.78. Therefore, it appears that the lateral Shoulder
Position
slide test 1) does reproduce the desired scapular points Dominant Nondominant
and the desired measurements, 2) is a reliable test in
terms of reproducibility, and 3) does test muscles that are Intratester reliability
actually working to stabilize the scapula. 1 0.85 0.87
The lateral slide test is not a true dynamic test in that 2 0.84 0.88
3 0.86 0.85
it does not measure scapular mobility during the throwing
motion and it does rely on static positions. However, the Intertester reliability
third position does accurately reproduce the position of 1 0.83 0.85
function of the shoulder and produces a significant load on 2 0.77 0.81
3 0.78 0.83
the scapular muscles. In addition, by keeping the shoulder
Vol. 26, No. 2, 1998 The Scapula in Athletic Shoulder Function 333
Figure 11. Closed-chain scapular exercises to simulate elevation (A), depression (B), retraction (C), and protraction (D).
336 Kibler American Journal of Sports Medicine
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