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research report

Nitin Kalra, PT, MS1 Amee L. Seitz, PT, PhD, OCS2 N. Douglas Boardman III, MD3 Lori A. Michener, PT, PhD, ATC, SCS4

Effect of Posture on Acromiohumeral


Distance With Arm Elevation in
Subjects With and Without Rotator
Cuff Disease Using Ultrasonography

houlder pain is the third most common musculoskeletal


problem, accounting for at least 21% of all musculoskeletal
complaints.36 The most common cause of shoulder pain is
rotator cuff disease (RCD), which includes impingement
syndrome, bursitis, tendinitis, tendinosis, and partial- and full-thickness
tears.37 Upper quadrant postural deviations have been linked to upper
t STUDY DESIGN: Controlled laboratory study.

t OBJECTIVES: To examine the effects of altering

posture on the subacromial space (SAS) in subjects with rotator cuff disease and subjects without
shoulder pain.

t BACKGROUND: Poor upper quadrant posture

has been linked to altered scapular mechanics,


which has been theorized to excessively reduce
SAS. However, no study has examined the direct
effects of altering upper quadrant posture on
SAS. We hypothesized that upright posture would
increase and slouched posture would decrease
the SAS, as compared to a normal posture, when
measured both with the shoulder at rest along the
side of the trunk and when maintained in 45 of
active shoulder abduction.

t METHODS: Participants included 2 groups:

the subjects with shoulder pain and rotator cuff


disease, as diagnosed via magnetic resonance
imaging (n = 31), and control subjects without
shoulder pain (n = 29). The SAS was imaged with
ultrasound using a 7.5-MHz linear transducer
placed in the coronal plane over the posterior to
midportion of the acromion. The SAS was measured on ultrasound images using the acromiohumeral distance (AHD), defined as the shortest

distance between the acromion and the humerus.


The AHD was measured in 2 trials at 2 arm angles
(at rest along the trunk and at 45 of active abduction) and across 3 postures (normal, slouched, and
upright), and averaged for data analysis.

t RESULTS: Two mixed-model analyses of variance,


1 for each arm angle, were used to compare AHD
across postures and between groups. There was no
interaction between group and posture, and no significant main effect of group for either arm position.
There was no significant main effect of posture for the
arm at rest (P = .26); however, there was a significant
main effect of posture on AHD at the 45 abduction
arm angle (P = .0002), with a significantly greater
AHD in upright posture (mean AHD, 9.8 mm), as
compared to normal posture (mean AHD, 8.6 mm).
t CONCLUSION: The effect of posture on SAS, as
measured by the 2-dimensional AHD using ultrasound of the posterior to middle aspect of the SAS,
is small. The AHD increased with upright posture
by 1.2 mm compared to normal posture, when the
arm was in 45 active abduction. J Orthop Sports
Phys Ther 2010;40(10):633-640. doi:10.2519/
jospt.2010.3155
t KEY WORDS: impingement, posture, rotator
cuff, shoulder, subacromial space

extremity
impairments 8,20,22
and
16,18,21,25,27
RCD.
A forward head posture has been linked to pain related to
shoulder overuse.16 Adopting a slouched
posture has been shown to decrease glenohumeral abduction strength,20 while
adopting an upright posture resulted
in increased glenohumeral elevation.8,22
Slouched posture may limit shoulder
motion due to impingement beneath the
acromion, creating a mechanical block
to shoulder elevation coupled with tissue
impingement.11,27,28 Taping applied to the
posterior trunk parallel to the thoracic
spine and over the scapula of patients
with shoulder pain increased thoracic
extension, reduced pain with shoulder
elevation, and improved resting scapular
position.22 Slouched posture is linked to
shoulder pain, changes in scapular position, shoulder strength, and range of motion, which may contribute to disability.
Mechanistically, upper quadrant posture can affect scapular motion or kinematics,9,12,20,21 which may reduce the
subacromial space (SAS) and contribute
to shoulder pain and the development of
RCD.6,16,21,23,24,27 Increased thoracic spine
kyphosis or slouched thoracic posture has
been shown to decrease scapular upward
rotation,20 posterior tilting,9,12,20 and external rotation.9,20,21 Patients with RCD,

1
Orthopaedic Physical Therapist, Select Physical Therapy, Fairfax, VA; Masters student [at time of study], Department of Anatomy and Physical Therapy, Virginia Commonwealth
University, Richmond, VA. 2Research Associate, Department of Physical Therapy, Virginia Commonwealth University, Richmond, VA. 3Associate Professor, Department
of Orthopedic Surgery, Virginia Commonwealth University Health Systems, Richmond, VA. 4Associate Professor, Department of Physical Therapy, Virginia Commonwealth
University, Richmond, VA. This study was completed as partial fulfillment for a Masters Degree in Anatomical Sciences from Virginia Commonwealth University. The study was
approved by The Institutional Review Board at Virginia Commonwealth University. Funding for this study was provided partially by the A. D. Williams Fund for Research at Virginia
Commonwealth University, the Department of Physical Therapy at Virginia Commonwealth University, and by the Foundation for Physical Therapy. Address correspondence to
Dr Lori A. Michener, Department of Physical Therapy, 1200 E Broad St, Richmond, VA, 23298. E-mail: lamichen@vcu.edu

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[
specifically, impingement syndrome,
have demonstrated these same altered
scapular kinematic patterns.23 These altered scapular kinematics may decrease
the SAS and clearance of the humeral
head beneath the acromion during arm
elevation.6,7,13,34,35 Studies provide some
support for this relationship. Artificially
induced scapular protraction, compared
to a position of scapular retraction, decreased the 2-dimensional (2-D) linear
distance between the acromion and humerusthe acromiohumeral distance
(AHD)as measured on magnetic resonance images (MRIs).35 Another study
found a reduced AHD measured on ultrasound images in tennis players without
shoulder pain but with scapular dyskinesis as compared to those without scapular
dyskinesis.34
Direct effects of posture on SAS for
individuals with RCD are unknown.
Subjects with acquired or idiopathic
thoracic hyperkyphosis have a smaller
AHD as measured on radiographic
images compared to nonkyphotic subjects.17 However, this study used subjects
without shoulder pain and measured
AHD with the arm at rest only. Moreover, slouched posture is not analogous
to hyperkyphosis, thereby limiting the
generalizability of these results. Studies
examining the direct effects of posture
on SAS in patients with RCD are needed to elucidate the relationship between
posture and RCD.
Generally, the AHD is smaller in patients with RCD as compared to healthy
shoulders.1,3,14,15,19 Studies using MRI reported a smaller AHD in patients with
impingement syndrome as compared
to healthy shoulders.1,15,19 Studies using
ultrasound imaging corroborate these
findings with a smaller AHD in patients
with RCD3,14 and a smaller AHD with increased severity of the RCD.3 Although
these studies consistently indicated a
smaller AHD with RCD, they varied on
the location of the measurement of the
SAS. MRI studies1,15,19 depicted the location as the anterior to middle aspect of
the SAS, or at the location of the small-

research report
TABLE 1

Descriptive Statistics*
Subjects With RCD (n = 31) Control Subjects (n = 29)

Age (y)

53.5 13.7 (20.0-80.0)

Height (cm)

170.2 9.6 (152.4-187.9)

Body mass (kg)

80.5 13.4 (60.2-115.1)

Pain (mo)

18.2 17.3 (2.0-84.0)

31.9 10.7 (23.0-62.0)


169.8 8.8 (151.1-1.9)
72.1 13.7 (56.6-113.3)
0.0 0.0 (0.0-0.0)

Abbreviation: RCD, rotator cuff disease.


* Data presented as mean SD (range).

est distance between the acromion and


humerus in the SAS. Studies using ultrasound imaged the SAS over the middle
SAS space,2,3 or did not state the exact location of the ultrasound transducer during imaging.14 Ultrasound as an imaging
modality is less costly and more practical than MRI, and has established concurrent validity with radiographic AHD
measures (r = 0.77-0.85).2,3
The link between upper quadrant
posture, shoulder pain, and RCD is not
well understood. Investigating the effects
of posture on the SAS of patients with
RCD will expand our understanding of
possible mechanisms of posture associated with RCD. Moreover, it may provide
mechanistic evidence for postural correction often used to treat these patients in
rehabilitation. The purpose of this study
was to determine the effect of posture on
SAS, using ultrasound images of the SAS
to measure the AHD in 2 arm positions
across 3 postures, in subjects with and
without RCD. We hypothesized that in
both groups slouched posture would lead
to a reduction in SAS and upright posture
would increase the SAS when compared
to normal posture, at both arm positions
of rest and 45 of active abduction.

METHODS
Subjects

ubjects with shoulder pain and


RCD (n = 31) and a control group
without shoulder pain (n = 29) were
recruited through the physician offices at
the University Health System and with
flyers posted at the Virginia Common-

wealth University Health System and Virginia Commonwealth University campus


(TABLE 1). The Institutional Review Board
at the Virginia Commonwealth University approved the study protocol and the
informed consent form, which was signed
prior to the data collection procedures.
Inclusion criteria for the RCD group
were (a) an age of at least 18 years, (b)
shoulder pain, (c) MRI confirmation
of RCD (tendinosis, bursitis, impingement, or partial- or full-thickness rotator cuff tear), and (d) ability to lift the
arm up to 90 of elevation, which would
ensure their ability to easily obtain and
easily maintain the 45 arm abduction
test position. If a subject had 2 or more
diagnoses, the more severe RCD pathology diagnosis was used to classify group
membership. Inclusion criteria for the
control group subjects were an age of at
least 18 years and having no pain and no
known previous or current shoulder pathology. Exclusion criteria for all subjects
were (a) a cervical range of motion that
reproduced shoulder pain, (b) pain below
the elbow indicative of cervical or nerve
pathologies, (c) past shoulder surgery,
and (d) glenohumeral joint arthritis, as
indicated in the MRI report.
Sample size was determined from a
pilot study,26 using AHD measures obtained from ultrasound images taken on
10 subjects with RCD and 10 subjects
without shoulder pain. Two ultrasound
images were collected with the arm at
rest and 45 active abduction, with the
subject in a neutral posture. This procedure was subsequently repeated 15 to 30
minutes later. The same methods were

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used as described in this study, using


the same investigator to collect data and
make AHD measurements. For the rest
and 45 arm positions, respectively, the
standard error of the measure (SEM) was
2.3 and 2.5 mm. Based on these data, we
calculated our desired sample size using
a desired minimal difference of 2.5 mm
between posture conditions. The average
standard deviation was conservatively estimated at 4.0 mm. For a power of 90%
and an alpha of .05, sample size calculations indicated 20 subjects per group.
As data collection ensued, the majority
of subjects in the RCD group had rotator cuff tears; therefore, recruitment was
extended to purposefully recruit subjects
with impingement to represent the entity
of RCD.

Procedures
After signing the informed consent form,
subjects completed an intake form and
the American Shoulder and Elbow Surgeons patient self-report shoulder score
to assess shoulder functional loss and disability (TABLE 2). Next, ultrasound images
of the SAS were collected for AHD measurement. The examiner was not blinded
to group assignment to conduct the ultrasound imaging, but was blinded for AHD
measurements.
Subacromial Space MeasurementThe
outlet of the SAS was measured on ultrasound-generated 2-D images via the
AHD. The AHD is a 2-D linear measure
defined as the shortest distance between
the acromion and the humerus (FIGURE 1).
An ultrasound unit (The Pyramid 764;
Pyramid Management LLC, Los Alamitos, CA) with a 7.5-MHz linear ultrasound
transducer was utilized. Placement of the
ultrasound transducer was standardized,
with its location on the posterior to middle portion of the acromion in the coronal
plane, with the transducer placed parallel
to the flat superior aspect of the acromion
so that both the acromion and humerus
were visualized (FIGURE 2). All ultrasound
images were saved on a computer for
AHD measurements performed later.
Two ultrasound images were taken for

TABLE 2

Subject Demographics
Subjects With RCD (n = 31) Control Subjects (n = 29)

Gender (n)
Male

11

14

Female

20

15

Dominant shoulder (n)


Right

22

27

Left

Ambidextrous

RCD diagnosis (n)


Impingement

15


Partial-thickness tear
9

Full-thickness tear
7
ASES pain score*

31.3 11.8 (10.0-50.0)

50.0 0.0 (50.0-50.0)

Function score 25.2 10.3 (5.0-45.0)

50.0 0.0 (50.0-50.0)

Total score 56.9 17.8 (28.0-95.0)

100.0 0.0 (100.0-100.0)

Abbreviations: ASES, American Shoulder and Elbow Surgeons Self-Report Form; RCD, rotator cuff
disease.
* Mean SD (range), 0-50 points, with 50 as no pain.

Mean SD (range), 0-50 points, with 50 as no functional loss.

Mean SD (range), 0-100 points, with 100 as no pain and functional loss.

FIGURE 2. Ultrasound probe positioning on the


acromion.

FIGURE 1. The line represents the acromiohumeral


distance (AHD).

each of 3 postures and 2 arm positions in


each posture.
Posture and Arm Angle Subjects were
tested in 3 sitting postures: (1) normal
resting posture, (2) slouched posture,
and (3) upright posture with scapular retraction. For normal posture, the subject
was asked to sit in a chair with the back
supported, feet flat on the floor, hips and

knees at 90 of flexion, head and shoulder in their habitual posture, looking


straight ahead (FIGURE 3). Slouched posture was achieved by having each subject
move forward in the chair so that the
subjects back was a minimum of 15 cm
away from the back support, then slump
forward and down to attain a flexed thoracic and lumbar spine, forward head,
and rounded shoulder posture (FIGURE
3). For the slouched posture position,
subjects were instructed to slouch down
but look straight ahead, to get flexion in
the thoracic and lower cervical spine, extension in the upper cervical spine, and

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research report

FIGURE 4. Subject with arm supported at 45


abduction.
FIGURE 3. (A) Normal posture. (B) Slouched posture. (C) Upright posture.

rounded shoulders. For upright posture,


subjects were asked to sit back against
the back rest of the chair with a pillow
between their back and the back support,
then were instructed to sit up straight
and pull their shoulders back and look
straight ahead, to achieve retracted
shoulders and extension in the thoracic
and cervical spine (FIGURE 3). For both
upright and slouched postures, subjects
altered both the spine and shoulder posture from their normal resting posture.
Therefore, changes in AHD between
postures can result from changes in spine
posture (thoracic or cervical spine) or
shoulder posture (humerus or scapula),
or a combination of these.
In all 3 postures, ultrasound images
were obtained at 2 arm angles: at rest
with arm at the side and in 45 actively
maintained coronal plane shoulder abduction. For the 45 position, the arm was
initially suspended in an adjustable sling,
but the arm was held actively above the
sling for imaging (FIGURE 4). This sling allowed the patient to rest the arm between
measurements and during setup. The
subject was instructed to hold the arm up
and off the sling for a few seconds, while
the arm angle was verified with a bubble
inclinometer. Then, ultrasound images
were captured with active arm elevation.
An elevated arm angle was used because
patients with RCD complain of pain during shoulder elevation. In pilot testing,
it was technically difficult to obtain adequate ultrasound images above 45 of

elevation. Moreover, measurement of the


SAS at angles greater than 45 may not
provide clinically relevant information
because, above 35 to 40 of glenohumeral elevation, the supraspinatus tendon
has likely already passed underneath the
acromion and may no longer be at risk of
impingement in the SAS.4
Each ultrasound image was an individual measure. Prior to each ultrasound
image, the subjects rolled their shoulders
and moved about to change their posture, then were asked to assume the designated posture and reposition the arm
in the appropriate arm angle. Between
measures at the 45 arm angle, subjects
took their arm out of the sling and then
repositioned the arm for the second ultrasound image. The sequence of postural alterations was counterbalanced by
changing the posture sequence, but the
resting arm position was always tested
prior to the 45 angle. Images were saved
to the computer, and retrieved later for
AHD measurement.
AHD Measurement The examiner who
captured the ultrasound images also
measured the AHD. Ultrasound images
were randomly retrieved, with the examiner blinded to group, arm angle, and
posture. The AHD was measured using
the software Universal Desktop Ruler
(AVP Inc, Voronezh, Russia) to measure
distances on screen. A mark was first
placed at the most inferior aspect of the
acromion, then a second mark was placed
at the humeral head to measure the

shortest distance between the acromion


and humerus. The 2 AHD measures at
each arm angle for each posture were averaged for data analysis.

Data Analysis
To examine the effect of posture on
AHD, 2 separate mixed-model analyses of variance (ANOVAs), 1 for each
arm position (rest and 45 abduction),
were performed. These included effects
for group (RCD and control), posture
(normal, upright, slouched), and groupposture interaction, with posture as the
repeated factor. Post hoc testing was performed using contrasts. All analyses used
a significance set at = .05. Test-retest
intrarater reliability was calculated using
an intraclass correlation coefficient (ICC)
2-way random analysis for each arm position. Error was calculated using SEM
(SD 1ICC) and minimal detectable
change (MDC) (SEM 2) values. The
90% confidence bounds were calculated
by multiplying error values by the z score
of 1.64.

RESULTS

he AHD means and standard


deviations are reported in TABLE 3.
Test-retest reliability analysis on
60 subjects revealed that for the rest and
45 abduction positions, respectively,
ICCs (2-way random) were 0.92 (95%
CI: 0.87, 0.95) and 0.76 (95% CI: 0.63,
0.86), SEMs were 0.9 and 1.6 mm, and
MDCs were 1.3 and 2.2 mm.
There were no significant group-

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TABLE 3

Acromiohumeral Distance*
Posture and Arm Elevation Angle
Normal Posture

Slouched Posture

Upright Posture

Rest

45 Abd Rest

45 Abd Rest

All subjects

8.6 1.9

9.2 1.9

12.1 2.6

12.5 3.1

12.6 2.5

45 Abd
9.8 2.0

Groups
Control

11.8 2.5

8.7 1.9

12.2 2.5

9.4 2.0

12.5 2.3

9.6 1.9

RCD

12.5 2.6

8.5 2.0

12.8 3.6

9.0 2.0

12.7 2.6

9.9 2.1

Subgroups of RCD
Impingement

12.8 2.5

8.6 2.4

12.9 4.0

8.3 1.7

12.8 2.4

9.8 1.7

Partial-thickness tear

12.0 2.1

8.6 1.8

13.6 2.6

9.4 1.8

12.8 2.2

11.1 2.5

Full-thickness tear

12.3 3.8

8.4 1.8

11.6 4.2

9.8 2.4

11.8 3.6

8.9 1.7

Abbreviations: Abd, shoulder abduction; RCD, rotator cuff disease.


* Data presented as mean SD mm. Subgroup definition based on magnetic resonance imaging.

Significantly different from normal posture (P = .002).

14

Acromiohumeral Distance (mm)

13

12

11

10

7
Normal

Slouch

At rest (0)

Upright

45 abduction

FIGURE 5. Acromiohumeral distance in millimeters for 3 postures and for 2 arm positions (at rest and 45
abduction). Data represent combined results for the control and patients with rotator cuff disease. Vertical bars
represent 95% confidence intervals.

posture interactions with the arm at rest


(F2,116 = 0.4, P = .658) and 45 abduction
(F2,115.4 = 1.0, P = .364). Therefore, the effect of posture was determined to be independent of group classification. Means
and standard deviations of all subjects
are reported in TABLE 3, and 95% CIs are

represented in FIGURE 5. There were no


statistically significant main effects of
group classification for either the rest
(F1,58 = 0.6, P = .431) or 45 abduction
(F1,58.1 = 0.04, P = .839) positions. Therefore, the difference between the control
and RCD groups was 0.5 mm (95% CI:

0.7, 1.7) with the arm at rest and 0.1 mm


(95% CI: 0.8, 0.9) for the 45 abduction position. There was no significant
main effect of posture with the arm at
rest (F2,116 = 1.4, P = .26); however, there
was a statistically significant main effect
of posture at 45 of abduction (F2,115.4 =
9.1, P = .0002). Post hoc testing, using
contrasts for the 45 arm abducted position, revealed a statistically significant
difference (t = 3.1, P = .002) of a greater
AHD in the upright posture (mean SD
AHD, 9.8 2.0 mm) compared to normal posture (mean SD AHD, 8.6 1.9
mm), with a mean difference of 1.2 mm
(95% CI: 0.3, 2.0). However, there was
no significant difference (t = 1.6, P = .106)
between slouched posture (mean SD
AHD, 9.2 1.9 mm) and normal posture
at the 45 abduction position.

DISCUSSION

he posture impairment theory


links postural deviations with anatomical changes, impairments, and
pain of the shoulder.6 Slouched posture
can alter scapular kinematics9,12,20,21; but
this posture is only theoretically linked
to a change in the outlet of the SAS.7,13,35
This study has demonstrated a link
between upper quadrant posture and
SAS, with a small change in the AHD

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[
2-D measure in the coronal plane of the
posterior to middle portion of the SAS.
Upright posture increased the AHD,
as compared to normal posture, when
the arm was actively held at 45 abduction but not when the arm was at rest.
Slouched posture did not change AHD
as compared to normal posture.
We examined the direct effect of
posture on the AHD linear measure in
patients with RCD and control subjects
at 2 arm angles. At 45 active abduction, AHD increased by a mean of 1.2
mm with a change from normal to the
upright posture. This supports the hypothesis that upright posture increases
AHD. This increase in AHD may have
the effect of relieving the symptoms of
compression of the SAS structures. The
meaningful change in AHD, the amount
needed to change patient symptoms and
shoulder function is unknown. Subjects
without shoulder pain but with thoracic
hyperkyphosis had 1.4 to 1.7 mm smaller
mean AHD than those without hyperkyphosis.17 A study of 4 healthy subjects
using MRI images of the midcoronal
plane, which approximated the middle
SAS, noted a mean AHD increase of 0.5
mm (range, 0.3-1.5 mm) with scapular
retraction as compared to protraction.35
In our study, the mean change of 1.2 mm
in AHD with upright posture was greater than that of the scapular protractionretraction study, but smaller than the
study of thoracic hyperkyphosis. The
MDC, the distribution-based error
for our AHD measure, was 2.2 mm. A
change in AHD of 2.2 mm from normal
to upright posture was experienced by
17 of 60 subjects (28%) in this study.
Although the AHD change with upright posture is statistically significant,
it was less than the MDC in 72% of the
subjects. The relationship of a 1.2-mm
change in AHD to patient symptoms is
unknown. Research is needed to determine the meaningful amount of change
in AHD.
Slouched posture was expected to decrease AHD when compared to normal
posture in both subjects with RCD and

research report
control. However, our results did not
confirm this hypothesis. What may partially explain this lack of difference is the
subject report of difficulty and pain while
maintaining their arm at 45 of abduction when in the slouched posture. Subjects might have elevated their scapula to
relieve pain, and this substitution movement might have prevented a reduction
in the AHD. Also, scapular muscle activity might have been altered with the
postures, and this might have an effect
on AHD. We did not monitor scapular
motion or muscle activity.
Upper quadrant posture is a combination of thoracic and cervical spine
posture, and shoulder posture of
the humerus and scapula. The components of upper quadrant posture
were not measured in the 3 postures.
Changes in shoulder and spine posture were inferred with the postures.
However, changes in components of
the upper quadrant posture could have
been inconsistent across subjects and,
therefore, would explain the lack of differences across postures.
The posterior to middle aspect of
the SAS was the best position to obtain
the landmarks for AHD measures with
ultrasound images. Prior studies using
ultrasound to measure the AHD in individuals with RCD imaged the SAS over
the middle2,3 or anterior10 aspect of the
SAS space, or did not describe location14
of the ultrasound probe. Findings from
these ultrasound studies were generally
consistent with those using MRI to image the SAS,1,15,19 which depicted the AHD
measure of the anterior to middle aspect
of the SAS or described it as the smallest
distance between the acromion and humerus regardless of location in the SAS.
There is evidence of greater humeral
contact on the anterior aspect of the acromion13 and a decrease of the anterior
aspect of the SAS with clinical impingement maneuvers30; however, the purpose
of this study was not to look at contact
or absolute values but to examine the effects of change in AHD with change in
posture. Additionally, no evidence indi-

]
cates that the anterior aspect differs from
the posterior aspect with respect to AHD
change during arm movement or altered
postures. A recent study33 comparing
changes in AHD with arm elevation between the anterior and posterior aspect of
SAS indicated that changes in AHD with
arm elevation were not significantly different when AHD was measured at the
anterior versus the posterior aspect of
the SAS. AHD was significantly smaller
in the anterior aspect of SAS compared to
posterior aspect, but the change in AHD
with arm elevation was not significantly
different. However, this does not exclude
the possibility that different effects of
posture on AHD might have occurred if
the anterior SAS was imaged. Measurement of the anterior SAS is indicated in
future studies.
The AHD measure does not represent
the entire SAS, rather, only a 2-D linear distance of a portion of the outlet of
the SAS. AHD measured on ultrasound
images are reliable2,3,10,38 and have demonstrated concurrent validity with radiographs (r = 0.77-0.85),2,3 and a high
correlation has been demonstrated between AHD measures taken with radiographs and those with MRI (r = 0.81).32
With 2-D imaging, significant projection
variations31 can be avoided with standardization of subject and transducer
position. The reliability of our AHD
measures were excellent, with all ICC
values greater than 0.75. Our results are
comparable to a recent reliability study
of AHD measured on ultrasound images
of patients with RCD, with reported reliability of 0.92 and 0.90 at rest and 60
abduction, respectively.29
There was no effect of the presence
or absence of RCD on AHD across postures and arm angles. Subjects in the RCD
group represented the broad spectrum of
the disease as identified by their MRI,
ranging from impingement syndrome to
partial-thickness and full-thickness rotator cuff tear. This supports external validity. However, this heterogeneity might have
limited the internal validity and, therefore,
the ability to detect differences between

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groups. In a prior study that measured


the AHD from ultrasound images taken
over the middle acromion,3 RCD severity
was linked to AHD, with a smaller AHD
in those with more severe RCD. Our RCD
subgroup data do not descriptively support this premise, which may be due to the
lower number of subjects or differences in
methods, as we generated our ultrasound
images from the middle to posterior aspect of the acromion.
Patients with RCD have pain with
shoulder elevation, suggesting that the
SAS should be measured at various positions of shoulder elevation. However,
evidence suggests that clinical relevance
of measuring SAS at elevation angles
greater than 35 to 40 of glenohumeral
elevation may not be important, as the
supraspinatus tendon has likely already
passed underneath the acromion and
thus may no longer be at risk of impingement in the SAS.4 Measurements of the
SAS and orientation of supraspinatus
tendon found that, anatomically, the supraspinatus tendon was at greatest risk of
impingement between the acromion and
greater tuberosity of humerus between
27.7 to 36.1.4,5
The healthy group was not age and
gender matched. Age of control subjects
(mean SD, 31.9 10.7 years) was significantly less (P.001) than the age of
the RCD group (mean SD, 53.5 13.7
years), with a mean difference of 21.8
years (95% CI: 15.2, 27.9). With aging,
there is a potential of osteophyte formation on the inferior acromion that could
affect the AHD measure. Gender was not
matched; however, there were no significant differences in distribution between
groups (P.05).
Postures were artificially induced in
a laboratory setting, therefore they may
not represent faulty postures seen in clients without shoulder pain or in patients
with shoulder pain. No intervention for
posture correction was given, so results
cannot be applied to the effects of a postural treatment. Lastly, the tester was not
blinded to group membership during ultrasound imaging of the SAS.

CONCLUSION

e examined the direct effects


of upper quadrant posture on the
SAS, using ultrasound to image
the SAS, performing a linear AHD measure in patients with RCD and control
subjects without shoulder pain. Upright
posture increased AHD in both groups of
subjects when tested in 45 actively held
abduction position. The AHD did not
differ between slouched posture as compared to normal posture, and between
those with or without the presence of
RCD in the 2 arm positions. The AHD
measure in this study represents only the
posterior to midportion of the SAS in the
coronal plane; therefore, results may differ for the anterior SAS. t

KEY POINTS
FINDINGS: Upright posture resulted in a

1.2-mm increase in SAS, as measured


by AHD, with the arm at 45 abduction, when compared to normal posture.
Change in AHD with upright posture
was not dependent on the presence or
absence of RCD. Slouched posture did
not induce a change in AHD, as compared to normal posture.
IMPLICATION: Upright posture can increase the SAS, as measured by the
AHD. However, the magnitude of the
change is small and within the range of
measurement error for the majority of
subjects.
CAUTION: Posture was artificially induced. Furthermore, the SAS was assessed using the AHD, which is a 2-D
measure and taken from ultrasound
images of the posterior to middle aspect
of the SAS.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

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