Does reaching the back reflect the actual internal rotation of the shoulder?

doi:10.1016/j.jse.2005.08.022

Journal of Shoulder and Elbow Surgery

Volume 15, Issue 3, May–June 2006, Pages 306-310

https://doi.org/10.1016/j.jse.2005.08.022 Get rights and content

To clarify the relationship between the vertebral level reached by the thumb and the internal rotation angle of the humerus, 7 shoulders in healthy volunteers were examined by use of an electromagnetic tracking device. Measurements were repeated in the hanging-arm position with the thumb pointing anteriorly and at the buttock, sacrum, and each vertebral level up to T6. From the hanging-arm position to the buttock, 54.3% of internal rotation occurred (mean, 39.8°), and from the buttock to the sacrum, 11.7% occurred (mean, 8.6°). In total, 66% of internal rotation occurred from the hanging-arm position to the sacrum. Above the sacrum, the contribution of elbow flexion to the level of the vertebral spine became much greater, and internal rotation of the shoulder did not change significantly above the T12 level. We recommend that the level of the thumb below the buttock be subdivided for more accurate assessment of internal rotation.

Section snippets

Subjects

Seven male volunteers without any history of shoulder disease were enrolled in this study. Their mean age was 28 years (range, 25-33 years). Only the right dominant shoulders were studied.

Measurement device

By use of an electromagnetic tracking device (3Space Fastrak; Polhemus, Colchester, VT) and analyzing software (3Space-Win; MP Japan, Tokyo, Japan) (Figure 1), the position and orientation of the sensors relative to the source were recorded. There were 4 sensors, attached to the ulnar head, the lateral

Results

Repeatability coefficients are summarized in Table I. With regard to rotation measurements, the angle of shoulder internal rotation increased greatly between the hanging-arm position and the buttock position. At this single interval, internal rotation increased by a mean of 39.8°, which occupied 54.3% of the entire range of internal rotation (Figure 4). From the buttock to the sacrum, 11.7% of internal rotation occurred (mean, 8.6°). In total, 66% of internal rotation occurred from the

Discussion

The error of the electromagnetic tracking device was found previously to be less than 0.5 mm for position and 0.5° for angulation.⁷ With the device attached to the surface of the skin, there may be greater error. To evaluate the error of this measurement system, we used the coefficient of repeatability, which is defined as 2 SDs of the differences between repeated measurements.¹ The coefficients of repeatability varied among the individuals, but they were small enough (<12% of measured values)

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Cited by (27)

Improved joint function when reaching behind the back is associated with patient reported outcomes in individuals with rotator cuff tears following exercise therapy
2024, Clinical Biomechanics
Reaching behind the back is painful for individuals with rotator cuff tears. The objectives of the study were to determine changes in glenohumeral kinematics when reaching behind the back, passive range of motion (RoM), patient reported outcomes and the relationships between kinematics and patient reported outcomes following exercise therapy.
Eighty-four individuals with symptomatic isolated supraspinatus tears were recruited for this prospective observational study. Glenohumeral kinematics were measured using biplane radiography during a reaching behind the back movement. Passive glenohumeral internal rotation and patient reported outcome measures were collected. Depending on data normality, appropriate tests were utilized to determine changes in variables. Spearman's correlations were utilized for associations, and Stuart-Maxwell tests for changes in distributions.
Maximum active glenohumeral internal rotation increased by 3.2° (P = 0.001), contact path length decreased by 5.5% glenoid size (P = 0.022), passive glenohumeral internal rotation RoM increased by 4.9° (P = 0.001), and Western Ontario Rotator Cuff Index and American Shoulder and Elbow Surgeons scores increased by 29.8 and 21.1 (P = 0.001), respectively. Changes in Western Ontario Rotator Cuff Index scores positively associated with changes in maximum active glenohumeral internal rotation and negatively associated with changes in contact path lengths (P = 0.008 and P = 0.006, respectively).
The reaching behind the back movement was useful in elucidating in-vivo mechanistic changes associated with patient reported outcomes. Glenohumeral joint function and patient reported outcomes improved, where changes in Western Ontario Rotator Cuff Index scores were associated with kinematics. These findings inform clinicians of functional changes following exercise therapy and new targetable treatment factors.
The effect of an early mobilization rehabilitation protocol on outcomes after reverse shoulder arthroplasty
2022, Seminars in Arthroplasty JSES
Citation Excerpt :
Pain was assessed by the NRS and ASES pain at each time point, and function was determined by SSV, ASES score, PSS, and CSS. ROM was assessed by the surgeons using a goniometer to determine forward elevation and external rotation with the patient’s arm at the side, whereas internal rotation was recorded as the highest thumb position reached in relation to the spine, a standard practice.22 The level of the thumb with relationship to the vertebral level was measured in five possible categories: thigh, buttock, sacroiliac, waist, and T12 vertebral level.
Given the continued growth of reverse shoulder arthroplasty (RSA), it is important to optimize factors that contribute to successful outcomes. Rehabilitation after RSA is critical to achieve successful outcomes including patient function and satisfaction; however, the ideal rehabilitation program has not been established. The purpose of this study was to evaluate the effect of early mobilization (EM) compared with delayed mobilization (DM) on outcomes and function after RSA.
A retrospective study of prospectively collected data was performed comparing 67 patients who underwent RSA in two groups: the EM group began a rehabilitation program immediately after surgery, and the DM group began after 4-6 weeks postoperatively. Preoperative and postoperative Constant shoulder score, American Shoulder and Elbow Surgeons (ASES) score, Penn Shoulder Score (PSS), shoulder satisfaction value as well as demographics, opioid usage, range of motion, 90-day complications, reoperation, and readmission rates were collected. Statistical analysis was performed between each group’s outcomes and for the change (delta) of outcomes from baseline to each postoperative time point.
At 6 weeks postoperatively, the EM group showed significantly higher scores in ASES function, PSS, active forward elevation, passive forward elevation, active external rotation, and passive external rotation. There was significantly lower narcotic usage in the EM group at 6 weeks. At 3 months postoperatively, the EM group showed a lower numerical rating score for pain and higher active forward elevation. At the last follow-up, there was a lower numerical rating score and greater degree for all ranges of motion for the EM group than that for the DM group. A greater change from baseline to 6 weeks postoperatively was seen for the EM group in shoulder satisfaction value, ASES function, PSS, active forward elevation, passive forward elevation, and internal rotation. From baseline to 3 months postoperatively, ASES pain, PSS, active forward elevation, and passive forward elevation improved significantly in the EM group. At the final follow-up, active forward elevation increased greater for the EM group. There were 3 complications (2 hematomas and 1 infection) in the DM group and none in the EM group.
The EM rehabilitation protocol after RSA achieved lower opioid usage at 6 weeks, lower pain scores at each time point, and better range of motion during the final follow-up than DM protocol. There were no complications reported with the EM protocol, suggesting it is a safe alternative for postoperative recovery. Orthopedic surgeons should consider the EM rehabilitation protocol after RSA.
Normalized hand-behind-back for the measurement of shoulder internal rotation
2022, JSES International
The hand-behind-back (HBB) is a method for measuring the range of shoulder internal rotation; here, the highest vertebral level reached by the thumb is recorded. Alternatively, other specific landmarks may be used to measure its distance with the thumb. When the records of distance are adopted, it becomes difficult to compare individuals of different physiques, that is, comparing adults and children. In this study, we proposed a modified HBB method that attempts to normalize body size disparity and examined its reliability.
Three raters measured the modified HBB in 60 healthy subjects. A test-retest design was used, wherein each rater measured one trial, for a total of three trials each subject. The subject's thumb was actively and passively ascended along the spinal column as high as possible; subsequently, the distance between the C7 spinous process and tip of the thumb (C7-thumb) was measured with a tape. The HBB ratio (HBBR) was used as the parameter of shoulder internal rotation. It was defined as the ratio between the C7-thumb and the distance between the C7 spinous process and midpoint of the line connecting the posterior superior iliac spines (C7-posterior superior iliac spine).
Intraclass correlation coefficients (model 2.1) ranged from 0.73 to 0.89, indicating that the reliability of the active and passive HBBR had moderate or good and good reliability, respectively. Bland-Altman analysis revealed that the values of minimal detectable changes were 0.053 and 0.036 for the active and passive measurements, respectively.
The proposed method was confirmed to have sufficient reliability for clinical use. The HBBR may be used as a parameter of the shoulder internal rotation, which enables the comparison between individuals of different physiques.
Thumb to spinous process is a false metric for glenohumeral internal rotation
2021, JSES Reviews, Reports, and Techniques
The measurement of internal rotation by noting the maximal vertebral level reached by the patient’s thumb behind their back is an established physical examination technique, as outlined in the American Shoulder and Elbow Surgeons Shoulder Assessment Form.⁷ The purpose of the present study is to correlate real-time glenohumeral internal rotation with thumb to spinous process movement to determine the accuracy of the technique.
Healthy volunteers with no previous history of shoulder injury or symptoms were recruited from the local medical school population. Ultrasound probe was placed over the anterolateral shoulder, and relevant anatomy was identified. Internal rotation was evaluated by measuring displacement of the peak of the medial aspect of the bicipital groove relative to the anterior glenoid rim with the arm held in defined positions of progressively increasing internal rotation. The difference in displacement between arm positions was calculated and recorded.
A total of 20 participants (11 women/9 men, aged 22-42 years) were recruited for measurement. A mixed-model repeated-measures analysis of variance was used. The most significant differences in displacement, and therefore internal rotation, were observed between the neutral and anterior superior iliac spine (0.21 ± 0.39 mm, P= .0269) and between the anterior superior iliac spine and peak iliac crest (0.26 ± 0.44 mm, P= .0163). After the peak iliac crest, there was no further statistically significant change in rotation.
The present study suggests that most glenohumeral internal rotation occurs before reaching the arm behind the back. Although not directly studied, this supports the notion that the maximal vertebral level reached involves an interplay of various joint motions. While the thumb to spinous process maneuver remains a functional evaluation, our results suggest a different examination technique be used to more accurately test glenohumeral internal rotation.
How internal rotation is measured in reverse total shoulder arthroplasty: a systematic review of the literature
2020, JSES International
Reverse total shoulder arthroplasty (RTSA) can lead to limited postoperative internal rotation (IR). We assessed how IR is measured and reported in the RTSA literature and examined the relationships between these measures and patient-reported ability to perform activities of daily living.
We searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials for articles published in English from January 2000 through September 2018 that reported clinical outcomes after RTSA (minimum 12-month follow-up). We included studies reporting IR range of motion (ROM) and/or patient-reported functional outcomes related to IR. We identified 255 studies, 35% of which were excluded because they reported no IR outcome measures, leaving 165 studies for analysis.
Studies reported 3 methods of measuring IR ROM: (1) vertebral level (VL) method (ie, the most proximal VL reached by the extended thumb with the arm behind the back), (2) degrees of IR with the arm abducted to 90°, and (3) degrees of IR with the arm in a neutral position. The VL measurement was reported in 89% of studies, but the methods of reporting this measure varied. Only 9% of studies reported functional outcomes related to IR. No study correlated clinical measurements of IR ROM with functional outcomes.
Measures and reporting of shoulder IR after RTSA varied widely. This variability makes it difficult to assess associations between postoperativce IR limitation and functional abilities. Standardization of IR measures and reporting is needed to allow meta-analysis of data related to this important outcome.
Validity of an Alternate Hand Behind Back Shoulder Range of Motion Measurement in Patients With Shoulder Pain and Movement Dysfunction
2018, Journal of Manipulative and Physiological Therapeutics
Citation Excerpt :
In the past, the movement of HBB has often been used interchangeably with internal rotation, with both thought to measure the same construct. However, previous research indicates a poor relationship between these 2 measures and hence it has been suggested that HBB ROM should be assessed in addition to the more usual physiological measures of shoulder movement in the cardinal planes.16,23 The various methods proposed to measure HBB ROM usually involve the use a tape measure or a modified standard goniometer.21
The purpose of this study was to determine the criterion-related validity of a novel method of measuring hand behind back (HBB) shoulder range of motion (ROM) for evaluating pain and disability in people with shoulder pain and movement impairment.
This cross-sectional study design evaluated shoulder ROM, pain, fear-avoidance beliefs, and disability in 60 people (aged 35-70 years, 31 male) with chronic unilateral shoulder dysfunction (mean duration 15.73 weeks). Shoulder HBB ROM was measured with a bubble inclinometer in a manner that did not require the patient to disrobe. Correlations were sought between HBB ROM and other shoulder movements, as well as scores recorded on the Shoulder Pain and Disability Index (SPADI), visual analogue scale for pain, Fear Avoidance Beliefs Questionnaire (FABQ), and duration of symptoms.
Restriction of HBB movement was significantly correlated with SPADI total disability score (r = 0.39, P < .01), flexion ROM (r = 0.30, P < .05), abduction ROM (r = 0.39, P < .01), and external rotation ROM (r = 0.60, P < .01). Other variables were not significantly correlated with HBB ROM. Multiple linear regression analysis indicated that the variance in HBB ROM was explained by the SPADI disability subscore (P = .01) but not by visual analogue scale score (P = .05), FABQ score (P = .65), or duration of symptoms (P = .73). The FABQ score was not explained by limitation in HBB ROM and shoulder movements.
These findings suggest that this novel method of measuring HBB ROM could be used as a functional outcome measure in the evaluation of patients with shoulder disorders. This method could be considered as an additional or alternative where there are challenges in measuring HBB because of restrictions in undressing a patient, such as for cultural reasons.

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Original articleDoes reaching the back reflect the actual internal rotation of the shoulder?

Section snippets

Subjects

Measurement device

Results

Discussion

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Statistical methods for assessing agreement between two methods of clinical measurement

Lancet

Original article
Does reaching the back reflect the actual internal rotation of the shoulder?