Knowledge of the normal

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1 Three-Dimensional Clavicular Motion During Arm Elevation: Reliability and Descriptive Data Paula M. Ludewig, PT, PhD 1 Stacy A. Behrens, PT, MS 2 Susan M. Meyer, PT, MS 3 Shawn M. Spoden, PT, MS 4 Laura A. Wilson, PT, MS 5 Journal of Orthopaedic & Sports Physical Therapy Study Design: Cross-sectional. Objectives: To determine the reliability of a surface sensor measurement of clavicular motion during arm elevation and to describe 3-dimensional clavicular motion in an asymptomatic population. Background: Abnormal scapular motion on the thorax has been implicated in shoulder pathology. Without the ability to measure clavicular motion, it is not possible to identify if abnormal scapular motions derive from the sternoclavicular or acromioclavicular joints. Methods and Measures: Thirty-nine subjects participated in the investigation, including an asymptomatic group (n = 3) and a group with a history or current symptoms of shoulder pathology (n = 9). Clavicular angles relative to the thorax were tracked with surface electromagnetic sensors on the thorax, clavicle, and humerus as subjects completed humeral flexion, scapular plane abduction, and abduction. Within-day reliability was assessed using intraclass correlation coefficients and SEM. Descriptive statistics quantified sternoclavicular joint motions for the various arm movements. Results: Reliable measurements were obtained, with intraclass correlation coefficients ranging from.93 to.99, and SEMs from.9 to 1.8. Between-day reliability SEM values were generally 2 to 4. During elevation of the arm, the clavicle with respect to the thorax generally undergoes elevation (11 maximum), retraction (15-29 maximum), and posterior long-axis rotation (15-31 maximum), with variability between subjects and planes of motion regarding the magnitude of motion. Conclusion: Rehabilitation approaches attempting to improve shoulder motion should benefit from improved knowledge of 3-dimensional contributions of the clavicle to normal and abnormal scapular kinematics. J Orthop Sports Phys Ther 24;34: Keywords: clavicle, kinematics, shoulder, sternoclavicular joint 1 Assistant Professor, Program in Physical Therapy, Department of Physical Medicine and Rehabilitation, The University of Minnesota, Minneapolis, MN. 2 Physical Therapist, NovaCare Rehabilitation, Coon Rapids, MN. 3 Physical Therapist, Abbott Northwestern, Minneapolis, MN. 4 Physical Therapist, Rusk County Memorial Hospital, Ladysmith, WI. 5 Physical Therapist, Park Nicollet Clinic, Maple Grove, MN. At the time this study was completed, Stacy Behrens, Susan Meyer, Shawn Spoden, and Laura Wilson were graduate students, Program in Physical Therapy, Department of Physical Medicine and Rehabilitation, University of Minnesota. This research was supported in part by an equipment grant from the Minnesota Medical Foundation. This study was approved by The Human Subjects Committee of the University of Minnesota Institutional Review Board. Address correspondence to Paula M. Ludewig, Department of Physical Medicine and Rehabilitation, The University of Minnesota, Minneapolis, MN ludew1@umn.edu Knowledge of the normal and abnormal shoulder mechanics and relationships to shoulder dysfunction has advanced considerably in recent years. Three-dimensional in vivo kinematics studies 18,23 and improving descriptions of shoulder kinetics 13,14 are enhancing our understanding of shoulder function. Abnormal scapular motions and positions relative to the thorax have been linked with various shoulder pathologies, including tendonitis, impingement, rotator cuff tears, and glenohumeral inferior instability. 1,17,2,25,32,35,36 Several investigators studying various patient populations have described abnormal scapulothoracic kinematics. In subjects with shoulder tendonitis or impingement, scapular winging, decreased upward rotation, increased internal rotation, and decreased posterior tipping have all been demonstrated under certain conditions. 19,2,35 In subjects with glenohumeral inferior instability, decreased scapular upward rotation has been identified as a possible contributing mechanism. 25 Because scapular motion on the thorax results in motion at the 14 Journal of Orthopaedic & Sports Physical Therapy

2 A Elevation X c Z c B Long axis rotation X c Y c Y c Protraction Depression X c Y c FIGURE 1. Clavicular axes and motions: X c = clavicular x axis, Y c = clavicular y axis, Z c = clavicular z axis, X s = scapular x axis, Y s = scapular y axis. (A) Anterior view of clavicle and sternum; (B) superior view of shoulder girdle. Figures adapted and reprinted with permission from Ludewig P, Functional anatomy and biomechanics. In: Home Study Course 11.1 Solutions to Shoulder Disorders. LaCrosse, WI: American Physical Therapy Association, Orthopaedic Section; 21. Journal of Orthopaedic & Sports Physical Therapy sternoclavicular (SC) joint and/or acromioclavicular (AC) joint, 7,12 abnormal scapular motions must be associated with abnormal motion at 1 or both of these joints. Due to the ligamentous and capsular attachments of the scapula to the clavicle and clavicle to the thorax, scapulothoracic motion requires SC or AC joint motion, or some combination of motion at both joints. 12 However, due to the difficulty of measuring in vivo clavicular motion and the greater ease of visualizing and recording scapular motion on the thorax, combined SC and AC joint motion has often been modeled and described as a single scapulothoracic joint motion. 2,18,2 Subsequently, little is known regarding the relative contributions of the SC and AC joints to total scapular motion in healthy subjects. Furthermore, specifically what contributions each of these joints make to identified scapular kinematic deviations is unknown. Without the ability to measure clavicular motion, current rehabilitative exercise programs for abnormal scapular kinematics are directed at the combined scapulothroracic linkage, rather than targeted to specific SC or AC joint abnormalities such as reduced joint mobility. Current knowledge of normal clavicular motion in vivo, and subsequently SC or AC joint motion, is based on a small number of studies. 5,12,22,34 Inman et al 12 were the first to measure clavicular motion and position as part of a comprehensive investigation of normal shoulder function. Using a combination of 2-D radiographic data and insertion of a pin into the clavicle of a single subject, these authors described clavicular elevation and posterior long-axis rotation at the SC joint (Figure 1) as the arm was progressively elevated in flexion or abduction. 12 Others have described progressive clavicular retraction as well as elevation at the SC joint during arm elevation in the scapular or coronal planes using static 5,34 or indirect measurement techniques. 22 These previous studies are limited by small sample sizes 12,22,31,34 or static measurements. 5,12,34 None of these past studies have directly captured complete 3-D clavicular motion in vivo. 5,12,22,31,34 In particular, beyond the early singlesubject work of Inman et al 12 and others, 31 clavicular long-axis rotation during active shoulder movements has not been quantified. An ability to simultaneously measure clavicular as well as scapular position and orientation would allow for descriptions of SC and AC joint motions in subjects with and without shoulder dysfunction. The purposes of this investigation were to determine the reliability of a surface sensor measurement of clavicular motion during arm elevation and, in the presence of reliable data, to describe 3-D clavicular motion in an asymptomatic population. METHODS Subjects Subjects between 18 and 5 years of age were eligible for this study, with the recruited convenience sample age ranging from 2 to 44. Subjects older than 5 were not recruited due to the possibility of asymptomatic degenerative changes of the SC or AC joints, which have been demonstrated to increase significantly beyond age Such asymptomatic bone structure changes could confound the interpretation of normal kinematics. Subjects completed a brief self-report questionnaire to obtain history and demographic information. Volunteers for the study were given a verbal and written summary of the study and prior to participation signed informed consent forms approved by The University of Minnesota Institutional Review Board. The rights of human subjects were protected. Based on a clinical screening examination, selfreported orthopaedic history, and demographic infor- RESEARCH REPORT J Orthop Sports Phys Ther Volume 34 Number 3 March

3 Journal of Orthopaedic & Sports Physical Therapy mation collected from the subjects, they were divided into 2 groups for data analysis (Table 1). The first group (n = 3) had no history, current symptoms, or positive clinical examination results for any shoulder pain or pathology. The second group (n = 9) had a history or current symptoms consistent with shoulder tendonitis and impingement, healed clavicular fracture, AC joint separation or glenohumeral joint dislocation, or mild thoracic scoliosis 21 (Table 1). Any of these conditions were considered possible contributors to abnormal clavicular kinematics. Although a comparison between groups of normal and abnormal clavicular kinematics was not the objective of this investigation, future studies may investigate such comparisons. Therefore, inclusion of a small sample of subjects with possible abnormal clavicular kinematics allowed for the assessment of reliability in both asymptomatic subjects and those with a history or current symptoms of shoulder pathology. The clinical screening examination was conducted to ensure subjects satisfied the inclusion/exclusion criteria for 1 of the assigned group classifications. The screening exam included goniometric shoulder range of motion assessment, visual assessment of cervical range of motion, resisted shoulder isometric contractions for pain provocation, and, based on history or symptoms, additional provocative screening tests, including impingement tests, 11,24 cervical provocation tests, 21 and a visual posture assessment and forward-bending scoliosis test. 21 Previous studies have identified that when using a cluster of impingement tests, clinical measures can have high sensitivity and specificity 4,16 and be valid diagnostic criteria for shoulder impingement syndrome (86% correct diagnosis) as compared to surgical confirmation. 33 However, sensitivity and specificity of clinical examination is not known for all individual screening tests utilized in this investigation. Subjects were excluded if they could not move the shoulder through a 14 range of motion into TABLE 1. Variables Subject demographics. flexion, abduction, and scapular plane abduction, as this was the humeral range of motion in which clavicular motion was assessed. Subjects were also excluded if they were experiencing current symptoms of cervical pathology (ie, neck pain, or upperextremity radiating symptoms of pain, numbness, or tingling), to remove subjects whose source of shoulder pain may have been referred from the cervical spine. Instrumentation The 3-D position and orientation of the thorax, clavicle, and humerus were tracked using a Polhemus Fastrak (Polhemus, Inc., Colchester, VT) electromagnetic motion capture system. Previous descriptions of this technology are available in the literature. 1,19 Data were collected at a 3-Hz sampling rate. The clavicular Mini Receiver 4A394-6 sensor dimensions (1.1 cm 3 ) were smaller than the standard sensor dimensions ( cm), to improve the ability to secure the surface sensor to the clavicle. Within a source-to-sensor separation of 76 cm, reported accuracy of the system is.15 for orientation and 1 mm for position. 28 Procedures Asymptomatic Group * (Mean ± SD) Fastrak sensors were applied with adhesive tape to the sternum, to the middle portion of the clavicle, and to the medial superior scapular acromion process (Figure 2). Once applied, clavicular sensor placement was evaluated and tracking of the sensor was confirmed statically and dynamically by assessing visual and palpable movement of the clavicle and sensor. If the clavicle could be seen or felt to move without associated sensor movement, sensor placement was adjusted. An additional sensor attached to a thermoplastic humeral cuff was secured to the distal humerus to track humeral motion. Subjects stood with their arms relaxed at their side while bony landmarks on the thorax, clavicle, and humerus were palpated Pathology Group (Mean ± SD) Age (y) 26.9 ± ± 3.3 Height (m) 1.77 ± ±.9 Weight (kg) 72.3 ± ± 11.3 Gender (% female) 47% 44% Diagnoses NA Tendonitis/impingement n=4 Clavicular fracture n = 2 Acromioclavicular Separation/glenohumeral Dislocation Thoracic scoliosis n = 1 n=2 * Asymptomatic subjects (n = 3). Subjects with a history or current symptoms of shoulder pathology (n = 9). 142 J Orthop Sports Phys Ther Volume 34 Number 3 March 24

4 functional range of motion for nonathletic activities, 26 while minimizing skin motion artifact of the surface sensor over the clavicle. Actual range of humeral elevation was available from the collected data set. The order of test motions was randomized between subjects. The dominant or pathologic side was tested for each subject. The sensors were not removed and replaced between repetitions or differing planar movements within day. Data Reduction Local coordinate systems were established for each segment based on the digitized anatomical coordinates and previously established methods. 17 The axis system for the thorax was aligned with the cardinal planes of the body. The vertical axis was formed by the vector joining the midpoints between the C7 spinous process and the sternal notch and between the T8 spinous process and the xiphoid process. The x-axis was directed to the right perpendicular to the sagittal plane. The y-axis was directed anterior perpendicular to the x- and z-axis. The clavicle axis system was aligned with the x-axis directed laterally along the long axis of the clavicle from the vector formed between the SC and AC landmarks, the z-axis initially aligned with the thorax z-axis when the subject was in a resting standing posture, and the y-axis directed anteriorly perpendicular to the x- and z-axis (Figure 1). The humeral z-axis was aligned parallel to the long axis of the humerus, the x-axis directed laterally parallel to a line between the medial and lateral epicondyles, and the y-axis directed anterior perpendicular to the x- and z-axis. These axis orientations were based on the recommendations of the International Society of Biomechanics Subcommittee for Standardization of Shoulder Kinematic Measurements. 23 Local coordinate systems for each sensor were mathematically transformed using matrix methods to be aligned with the anatomically defined axes. 6 Clavicular motions relative to the thorax (SC joint) were subsequently described as protraction/retraction about the z-axis, elevation/ depression about the y-axis, and anterior/posterior long-axis rotation about the x-axis (z, y, x ordered Cardan angles, Figure 1). Based on the defined axes orientations, clavicular protraction, depression, and posterior rotation were positive rotations. Journal of Orthopaedic & Sports Physical Therapy FIGURE 2. Sensor placements on the thorax, clavicle, and humerus. and digitized. Thorax and humeral landmarks included the sternal notch, C7 spinous process, the xiphoid process, T8 spinous process, superior and inferior humeral cuff points aligned with the long axis of the humerus, and the medial and lateral epicondyles, following recommendations of the International Society of Biomechanics Subcommittee for Standardization of Shoulder Kinematic Measurements. 17,23 Clavicular landmarks included the anterior superior SC and AC joints on the proximal and distal clavicle respectively (Figure 1). Digitizing involves bringing a stylus with an embedded electromagnetic sensor and known tip offsets to the palpated landmark location and digitally recording the 3-dimensional coordinate locations relative to the respective segment sensor. Reliability and validity of this method of tracking humeral motion has been previously described. 17,19 For the current study, in a randomly selected subsample of subjects, the thorax and clavicle landmarks were digitized a second time by the same investigator (n = 11 subjects) or by a second investigator (n = 5 subjects) to assess the intrarater and interrater reliability of the digitizing procedures. A small sample of subjects (n = 5) also were tested 2 days in succession, with removal and replacement of sensors and redigitizing completed for each session to determine between-day reliability. Kinematic data were collected for 5 seconds in a relaxed standing posture. After practice and demonstration of the ability to control the speed of motion in the appropriate plane, subjects were instructed to complete 3 repetitions for each test motion (sagittal plane flexion, scapular plane abduction, and coronal plane abduction of the arm) at 1 complete cycle every 4 seconds. Subjects maintained light fingertip contact with a flat planar surface to guide motions in the appropriate plane. Scapular plane abduction was defined as 4 anterior to the coronal plane. Motions were performed to approximately 12 of arm elevation, based on the visual estimation of the investigator. This range of motion was selected to represent Data Analysis Data for the 3 dependent variables of clavicular rotations were selected at specific humeral elevation angles for each humeral motion, subject, and repetition. For the reliability portion of the study, humeral angles of 25, 5, 75, 1, and 115 relative to the thorax were selected. Angles above 115 were not considered as sensor tracking above this angle appeared poor. For the descriptive portion of the study, RESEARCH REPORT J Orthop Sports Phys Ther Volume 34 Number 3 March

5 Journal of Orthopaedic & Sports Physical Therapy humeral angles were selected at 1 intervals, starting at 1 and progressing to 11 of humeral elevation. Descriptive data were also available for clavicular position with the arm relaxed at the side. Reliability statistics included intraclass correlation coefficients (ICC 3,1 ) and the standard error of measurement (SEM). 8,29 The SEM was calculated as the square root of the within-subjects mean-square error term from a 1-way analysis of variance (ANOVA). 8 Reliability values were determined across the 3 repetitions for each subject (within day, trial to trial). Values were calculated for each test motion (flexion, scapular plane abduction, abduction), each dependent variable (clavicular protraction/retraction, elevation/depression, and long-axis rotation), each group, and each humeral angle, resulting in 9 ICC and SEM values. Due to minimal variation across humeral angles, values were subsequently averaged across angles reducing the data to 18 ICC and SEM values. Because of the smaller number of subjects and limited between-subject variability for reliability assessment across digitizing trials (intrarater), between digitizers (interrater), and between days, only the SEM values were determined for these conditions. As a proportional statistic, valid ICC values are dependent on significant between-subject variability, whereas SEM values are a within-subject statistic independent of between-subject variance. 29 Descriptive statistics were calculated for the asymptomatic group. Values at each humeral elevation angle for each test motion were averaged across the 3 repetitions. Means and standard deviations were then calculated across subjects for each test motion (flexion, scapular plane abduction, abduction). RESULTS When trial-to-trial reliability analysis was completed separately at each humeral angle, the greatest variation in reliability across humeral angles was.3 for ICC values and.9 for SEM values during scapular plane abduction (Table 2). Averaged across humeral angles, ICCs ranged from.96 to.98 for the asymptomatic group and.93 to.99 for the pathology group, and SEMs ranged from.8 to 1.8 and.8 to 2.5 in these groups, respectively (Table 3). No pattern of decreased reliability in subjects with a history or symptoms of pathology was apparent. For the subgroup of subjects involved in redigitizing, SEMs for intrarater and interrater reliability within day were generally around 1 to 2, with the highest value being 4.1 for interrater protraction/retraction values (Table 4). Consistent with within-day data, between-day reliability values also demonstrated minimal variation across humeral angles, with the greatest variation between angles (1.6 ) occurring during abduction. No consistent pattern of decreased reli- TABLE 2. Intraclass correlation coefficient values (and SEM) for increasing humeral angles during scapular plane abduction for healthy subjects (n = 3). Elevation/ Depression Long-Axis Rotation Protraction/ (.8 ).98 (1.2 ).96 (1.5 ) 5.94 (.9 ).98 (1.3 ).97 (1.3 ) (.9 ).98 (1.5 ).98 (1.1 ) 1.97 (.9 ).98 (1.8 ).98 (1.1 ) (.9 ).98 (2.1 ).98 (1.1 ) TABLE 3. Intraclass correlation coefficient values (and SEM) for clavicular motion averaged across humeral angles. Elevation/ Depression Long-Axis Rotation Protraction/ Asymptomatic group Flexion.97 (1.1 ).98 (1.8 ).96 (1.4 ) Abduction.98 (.9 ).98 (1.2 ).96 (1.3 ) Scapular plane abduction.96 (.9 ).98 (1.6 ).97 (1.2 ) Pathology group Flexion.95 (1.4 ).96 (2. ).96 (1.8 ) Abduction.96 (1.1 ).99 (.8 ).93 (2.5 ) Scapular plane abduction.96 (1.1 ).97 (1.5 ).98 (1.2 ) TABLE 4. SEMs for intrarater and interrater reliability of redigitizing and between-day reliability. Elevation/ Depression Long-Axis Rotation Protraction/ Within day Intrarater (n = 11) Interrater (n = 5) Between day (n = 5) Abduction Scapular plane abduction Flexion ability at higher humeral elevation angles was present. Between-day reliability SEM values averaged across humeral angles were slightly higher than within-day values, generally in the range of 2 to 4 (Table 4). For the asymptomatic group, the average clavicular position during relaxed standing included slight elevation (mean ± SD, 1.6 ± 3.3 ), retraction (mean ± SD, 18.2 ± 5.8 ), and near neutral long-axis rotation (mean ± SD,.5 ± 2.5 ). From this initial position, the clavicle showed similar patterns of progressive elevation and posterior long-axis rotation as the arm was elevated in any of the measured planes of motion (Figures 3-5). The average clavicle retraction position 144 J Orthop Sports Phys Ther Volume 34 Number 3 March 24

6 Clavicular Elevation Angle (degrees) l -5 Elevation Clavicular Elevation Angle (degrees) -5 Elevation Journal of Orthopaedic & Sports Physical Therapy Clavicular Long-Axis Rotation Angle (degrees) Clavicular Protraction/ Angle (degrees) Posterior Rotation Humeral angle (degrees) FIGURE 3. Data (mean and standard deviation) for clavicular angles during humeral flexion. Top graph represents elevation, middle graph posterior rotation, and bottom graph retraction. remained essentially unchanged during flexion, but became progressively retracted during abduction in the scapular and coronal planes. Although the mean values for retraction in flexion made it appear that the clavicle remained stable, upon visual inspection of the individual subject graphs, only 2 individuals demonstrated no change in retraction as the arm was flexed. The variability among the remaining subjects (some subjects demonstrated a less retracted position and some a more retracted position as the arm was Clavicular Long-Axis Rotation Angle (degrees) Clavicular Protraction/ Angle (degrees) Posterior Rotation 12 Humeral angle (degrees) FIGURE 4. Data (mean and SD) for clavicular angles during humeral scapular plane abduction. Top graph represents elevation, middle graph posterior rotation, and bottom graph retraction. flexed) resulted in the average appearance of an unchanged clavicular retraction angle. In the asymptomatic group, the average magnitude of clavicular retraction at the 11 humeral angle was greatest for coronal plane abduction ( 28.7 ) and least for flexion ( 14.9 ). The average magnitude of clavicular elevation showed the opposite trend with the greatest value at 11 of flexion ( 15. ) as compared to 11.1 and 12.2 for scapular plane and coronal plane abduction, respectively. Average RESEARCH REPORT J Orthop Sports Phys Ther Volume 34 Number 3 March

7 Clavicular Elevation Angle (degrees) Clavicular Long-Axis Rotation Angle (degrees) Clavicular Protraction/ Angle (degrees) l Journal of Orthopaedic & Sports Physical Therapy FIGURE 5. Data (mean and SD) for clavicular angles during humeral abduction. Top graph represents elevation, middle graph posterior rotation, and bottom graph retraction. clavicular posterior long-axis rotation was also greatest at 11 of flexion (31.3 ) as compared to scapularplane (18.2 ) and coronal plane abduction (14.6 ) (Figures 3-5). DISCUSSION Elevation Posterior Rotation Humeral angle (degrees) Recent methodological advances have allowed for reliable and accurate surface tracking of the scapula during dynamic movements of the arm. 15 Previous to the current study, no attempt had been made to similarly track the 3-D movements of the clavicle during elevation of the arm in vivo. Our study presents a reliable method for in vivo clavicular motion analysis using a surface marker. Such tracking is necessary in combination with scapular tracking to allow for identification of the SC and AC component motions associated with normal and abnormal motions of the scapula on the thorax, as well as to allow investigation of SC joint kinematic abnormalities. As the scapulothoracic joint is actually a linkage of the SC and AC joints, abnormal scapulothoracic motion must be related to abnormal kinematics of either the SC or AC joint, or both in combination. The addition of clavicular data to shoulder motion analysis protocols will allow for a complete shoulder complex motion description and advancement of our understanding of shoulder kinematics. Although the predominate sample included healthy subjects, a small group of subjects with a history or current symptoms of shoulder pathology with the potential to impact clavicular motion was included in this investigation. Because the intent of future work is to determine any SC and AC kinematic differences between subjects with and without shoulder pathology, as well as to describe relative SC and AC joint contributions to scapular motion in healthy subjects, it was of interest to determine if reliability of the clavicular tracking measure was maintained in subjects with pathology. The consistency of reliability statistics between groups suggests that larger investigations involving patients with shoulder pathology are feasible. The palpation and digitization process is completed to realign sensor orientation values to an anatomically based coordinate system. Subsequently, sensor placement can be based on surface locations that minimize skin motion artifact, and variations in initial sensor alignment have less impact on the repeatability of the measurement. A source of reproducibility error results from variation in palpation and digitization of the anatomical landmarks that form the basis of the anatomical coordinate system. Thus the intrarater and interrater reliability of the digitizing are important to consider. SEM values with redigitizing were generally within 1 to 2, with the highest value being 4.1. Values for between-day reliability during motion were slightly higher (2-4 ), indicating that the digitizing process does not completely eliminate effects of variations in sensor alignment. These values compare favorably to within- and between-day reproducibility of 2 to 3 for surface tracking of scapular motion. 17 Inman et al 12 proposed that scapular upward rotation on the thorax during arm elevation was roughly equally divided between contributions from elevation at the SC joint and upward rotation at the AC joint. Based on extrapolation from their graphical results, 146 J Orthop Sports Phys Ther Volume 34 Number 3 March 24

8 Journal of Orthopaedic & Sports Physical Therapy they reported approximately 2 of elevation of the clavicle by 11 of humeral elevation 12 as compared to our substantially lower values for this motion. In contrast, our results demonstrated higher values for posterior long-axis rotation, as compared to approximately 15 for flexion to 1 and 1 for abduction to 11 reported by Inman et al. 12 We believe the primary reasons for these differences are the 2-D measurement methods and limited sample size of Inman et al s 12 data. However, because these previous authors did not report details of their subject sample or variability data between subjects (only 1 subject was tested for long-axis rotation), and because we used a surface sensor, a different underlying subject population between studies or skin motion artifact in our data cannot be ruled out. Our results are more similar to the data recently reported by McClure et al. 22 These authors used a scapular sensor attached to a bone pin, a surface sensor on the thorax, and assumptions of constant distances between these sensors and the AC joint and sternal notch, respectively, to test 8 healthy subjects. 22 Thus, clavicular motion was not directly tracked, but protraction/retraction and elevation angles were derived from the scapular and thorax sensors. They report clavicular elevation angles of approximately 2 and 8 at 25 and 11 of humeral elevation in the scapular plane, and 4 and 11 for humeral elevation in flexion. 22 For clavicular retraction, McClure et al 22 report approximately 19 and 28 for scapular plane abduction and 17 and 25 for flexion at the 25 and 11 humeral elevation angles, respectively. When considering a slight difference in initial alignment of their thorax reference frame, except for clavicular retraction during humeral flexion, these values are virtually identical to our results. However, the indirect method does not allow for descriptions of long-axis rotation and relies on the assumption of a rigid linkage between the scapular sensor and clavicle landmarks. Cases of AC joint laxity would violate this assumption of a rigid clavicle/scapular link. Currently, the sensitivity of indirect clavicular measurements to violations of the rigid link assumption is unknown and a direct clavicular measurement method may be advantageous. Despite differences in magnitude, the current investigation and all previous studies completed are in general agreement with regard to the direction or patterns of clavicular motion during humeral elevation. Clavicular elevation, posterior long-axis rotation, and retraction are the generally described rotations with elevation of the arm in the coronal or scapular planes. 5,12,22,34 Fung et al 9 also report these same patterns when tracking 3-D clavicular motion during passive humeral elevation in a cadaver model. Greater variability is present in the reporting of clavicular protraction/retraction with humeral flexion. The implications of the variations in the magnitudes of motion between our study and that of previous work are important to consider. Because of the direct mechanical linkage of the clavicle to the scapula, movements at the SC joint must either result in scapular motion on the thorax, or be offset by opposing motions at the AC joint. 12 The available literature indicates that during elevation of the arm, SC and AC joint motions are both linked with scapular motion on the thorax. 5,9,12 The common anatomical descriptions of SC joint axes orientations and those of the scapula on the thorax are not directly parallel (Figure 1B). When considering these differing axis alignments, elevation and posterior long-axis rotation at the SC joint should both occur with upward rotation of the scapula on the thorax. In addition, posterior long-axis rotation at the SC joint should occur with scapular posterior tipping, and protraction and retraction of the clavicle at the SC joint should occur with scapular internal/ external rotation (Figure 1B). When comparing our 3-D data to Inman et al s 2-D values, 12 clavicular elevation during humeral elevation appears to demonstrate substantially less than 5% of the motion of scapular upward rotation. The remaining scapular upward rotation during humeral elevation would, therefore, have to occur either with clavicular posterior long-axis rotation or AC joint upward rotation. Thus, although minimally investigated, posterior rotation of the clavicle is likely an important component of normal shoulder motion because of its relationship to both upward rotation and posterior tipping of the scapula. The objectives of this study did not include statistical between-group comparisons. Exploration of pathology group data was restricted to reliability analyses due to the small number of subjects and heterogeneous sample with regard to diagnoses. However, reductions in clavicular long-axis rotation may be of particular interest for future investigation because such deviations could be associated with decreased scapular upward rotation and posterior tipping, which would increase the potential for glenohumeral impingement. 17,2 The association of clavicular posterior rotation and scapular posterior tipping may be of particular interest because of the recurring finding of reduced posterior tipping in patients with impingement. 17,2 Alternatively, SC joint motion reductions could require greater motion of the AC joint to maintain normal scapular motion on the thorax, possibly increasing AC joint stresses and the potential for degenerative changes. Past literature has also indicated SC joint dysfunction can result in abnormal scapular winging. 3 Further study is needed to fully describe the SC and AC joint movement during scapular motion on the thorax, and to determine the effects of disruptions of the clavicular scapular linkage on kinematics in pathological states. 3 RESEARCH REPORT J Orthop Sports Phys Ther Volume 34 Number 3 March

9 Journal of Orthopaedic & Sports Physical Therapy Because the differing SC and AC joint axes of rotation both contribute to scapular motion on the thorax, it may be beneficial to distinguish the relative contributions of the SC and AC joints when assessing patients and exercise approaches. Future work is needed to further delineate 3-D muscle function at the SC and AC joints and develop clinical methods to measure SC and AC joint motion as to refine rehabilitation approaches for shoulder pathology. A primary limitation of any investigation using surface markers to track underlying bone motion is the error in measurement introduced by skin motion artifact. Preliminary data from our lab indicate the ability to closely track underlying clavicular motion with a surface sensor at lower humeral elevation angles. Surface tracking, as compared to bone-fixed sensor motion during passive humeral elevation to 1 abduction in cadaver specimens, resulted in root-mean-square errors of 1, 1, and 4 (13%, 7%, and 27% of total motion) for clavicular elevation, retraction, and long-axis rotation, respectively. The patterns of motion were similar throughout the motion for both surface and bone-fixed sensors. Greater error in measurement of axial rotations is a common difficulty with surface sensor measurements of human motion. 19 As an additional assessment of the validity of our data, we calculated clavicular elevation and protraction/retraction angles for the first 5 subjects, using the indirect method assuming a constant distance between the sternal notch relative to the thorax sensor and the AC joint relative to the acromial sensor. 15,22 Clavicular elevation was then defined as the projection angle of this clavicle distance vector on the thorax coronal plane and protraction/ retraction as the projection angle on the thorax transverse plane. The root-mean-square differences between our clavicular surface sensor angles and the indirect method were 1.4 for protraction/retraction and 2.7 for elevation. These small differences appear reasonable, considering skin motion errors are also present with the indirect method, and the use of the sternal notch of the thorax rather than the SC joint of the clavicle creates a slight increase in the value of the clavicular elevation angle. Further investigation in vivo is necessary to quantify the accuracy and validity of tracking clavicular motion with surface sensors during active motions and to determine if systematic offsets amenable to correction equations could be used to improve accuracy. Additionally, in several subjects, substantial skin motion artifact of the sensor appeared to occur at elevation angles beyond approximately 11 of humeral elevation. Based on the similarity of our data to bone pin motion of posterior long-axis rotation, 12,31 adequate skin tension appears present to rotate the surface sensor with the underlying clavicle at lower humeral elevation angles. However, our visual observation was that at angles beyond 115 of humeral elevation, the movement of the clavicle beneath the skin does not appear to be well captured. Although most functional activities do not require higher elevation angles of the arm, 26 to fully describe available motion at the SC joint, an improved sensor attachment that would allow tracking of full elevation motions would be desirable. Another limitation of this study is that subjects tested were not fully representative of the population as a whole. Most subjects were slender, with an average body mass index of 23 kg/m 2. Heavier subjects would likely have greater skin motion artifact errors with surface tracking. Alternative methods of sensor attachment should be explored to allow testing of a broader range of body types. CONCLUSION Reliable 3-D measurement of clavicular motion during arm elevation can be obtained in vivo with a surface sensor. During elevation of the arm, the clavicle generally undergoes slight elevation, slight retraction, and posterior long-axis rotation, with variability between subjects regarding the magnitude of motion. This study expands on the previously limited data available on SC joint kinematics and provides the only in vivo dynamic description of simultaneous clavicular motion about all 3 axes of rotation. Rehabilitation approaches attempting to improve overall scapular motion and control on the thorax during functional movements of the shoulder and arm would benefit from improved knowledge of 3-D contributions of the SC and AC joint to normal and abnormal scapular kinematics. Further data are needed to quantify the validity of this technique. References 1. An KN, Jacobsen MC, Berglund LJ, Chao EY. Application of a magnetic tracking device to kinesiologic studies. J Biomech. 1988;21: Babyar SR. 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