Shoulder balance is considered characteristic of idiopathic scoliosis. Use of clinical photography to measure ShB has not been fully analyzed. Clinical photography offers a series of practical advantages: it is cheap, simple to handle and images are almost immediately available. The aims of our research were to determine the reliability of various measurements taken using digital photography and to evaluate their relationship with radiological parameters in a non-selected population of patients with idiopathic scoliosis.
Selection of measurements
An initial step to design the research was to decide which measurement to include in the study. It was decided to select angular measurements to avoid problems from the calibration necessary when using linear measurements. In the case of asymmetry of the trapezium muscles, it was preferred to use angular measurements instead of surface areas as we believe that the latter is more complex and not very useful in daily clinical practice. We also ruled out using skin markers as other authors had done previously. We believe that this methodology lengthens examination time and introduces a new source of bias. We therefore preferred to define, a priori, the anatomic points to be used as a reference for the measurements.
After these prior considerations, it was decided to record three parameters:
1.
Shoulder height angle (SHA): formed between the line that joins the upper border of both acromion processes and the horizontal. This is the parameter which should, a priori, collate shoulder imbalance better. This parameter has been used previously by other researchers both for front [
9],[
12] and back [
6],[
9],[
12] photography. Some authors [
18] have used the linear measurement by calculating the difference in cm from the upper border of each acromion process to a horizontal line perpendicular to the axillary fold. This methodology requires calibration, whereby it was rejected. Furthermore, for SHA we only have reliable data from back photography [
11].
2.
The left/right ratio trapezium angle (LRTA) reported as the angle formed by the external border of the trapezium muscle with the horizontal. We think this could be equivalent to the Ln [L/R Trapezium Area] reported by Ono [
12]. These authors found a statistically significant correlation between this parameter and the radiological variables. Nonetheless, there are no reliable data for this measurement and, in our opinion; its calculation is excessively complex for routine use. The possibility of recording an evaluation parameter for the trapezium area was put forth by prior publications which indicate its relationship with the proximal thoracic curve.
3.
Axilla height angle (AHA): formed between the line that joins the upper border of both acromion processes and the horizontal. This parameter has also been used previously [
6],[
11]. It was decided to include it to analyze its possible relationship with radiological shoulder imbalance with the intention of having a second parameter to estimate shoulder imbalance for those cases when SHA is not reliable. For AHA we only have reliable data from the measurement during back photography [
11].
Reliability and concordance
Most of the measurements selected revealed excellent-near perfect intra and inter observer reliability (ICC > 0.70); the inter-observer ICC were slightly less, a data already reported by other authors [
19]. The reliability data are very similar for frontal and back views. Yang et al. reported somewhat more reliability (intra-observer reliability 0.97 for both measurements and inter-observer reliability 0.99 and 0.97 respectively) for the back photography [
11]. The intra and inter-observer reliability values for LRTA, SHA and AHA from the front, used in our work, have not been previously published.
We found poor concordance between SHA and AHA, which suggests that one measurement cannot estimate another when analyzing the clinical balance of the shoulders. Similarly, when evaluating the concordance between front and back SHA we found poor concordance between both measurements (CCC 0.49, 95% CI 0.32-0.64); this indicates that both measurements are not interchangeable between themselves.
Relationship between the photographic and radiological measurements
Overall, the correlations found between clinical and radiological parameters may be considered moderate to poor and in no case greater than 0.6. Behavior was similar for the three parameters evaluated (SHA, AHA and LRTA) for the two photographic views (front and back). This low correlation is similar to that reported when analyzing correlations between the radiological parameters and those obtained with the topographic analysis technique [
20].
From our results, the lack of correlation between clinical ShB and magnitude of the PTC curve is notable; because it is usually accepted, that one of the factors that has an impact on shoulder imbalance, is the structural nature of this curve. Other previous publications had found poor or inexistent correlations between radiographic and photographic measurements in type 1 and 2 Lenke curve series [
6],[
9],[
12],[
21]. These data suggest that the PTC does not have a significant impact on clinical shoulder balance. Conversely, we have found a moderate correlation between MTC and TLLC and the photographic measurements of the ShB, especially with the back AHA (r = −0.44). Yang and Qiu found a similar correlation [
6],[
9] and Hong et al. reported that post-operative ShB in a series of patients who had received surgery, was related to the correction of the MTC and TLLC [
22]. These findings would indicate that clinical ShB would in part be influenced by the magnitude of the main thoracic curve and the lumbar curve. The tilt of the end vertebrae for the different curves correlated in a similar way to those overall values of the curves with the photographic measurements. No especially interesting correlation was found; therefore, the vertebra to vertebra analysis does not appear to be useful. Overall, the parameters measured in the frontal view reveal correlations with the radiographic measurements somewhat higher than those found for the rear view. Specifically, we have to point out the correlation between SHA and CRIA (r = 0.48) and SHA and T1-tilt (r = 0.51). Therefore, we would venture to recommend that the study of ShB be performed on photography taken from a frontal view, although we are aware that this shot may be a reason for conflict or rejection, especially in the case of women.
The photographic parameters (SHA, AHA, LRTA) were moderately correlated with CRIA and T1 tilt. We hypothesize that CRIA would be the radiological equivalent of SHA. Different parameters were used for the radiological measurement of ShB: Coracoids’ height difference (CHD) [
5],[
21],[
23], clavicular angle (CA) [
5],[
23], clavicle-rib intersection difference (CRID) [
23], radiological shoulder height (RSH) [
5],[
23] or first rib angle (FRA) [
9],[
12] among others. Our initial intention was to use clavicular angle (CA) as a radiological measure of ShB considering the high level of reliability of the measurement reported by Hong et al. [
5]. Nonetheless, we find that for a high percentage of patients both shoulders on the x-rays could not be observed. For this reason, we decided to use the point where the clavicle crosses the ribcage as a reference point. Bagó et al. [
23] found an excellent correlation between the difference in real shoulder height and that measurement at this reference point.
The correlation between SHA and CRIA was less than expected taking into account the fact that, theoretically, both measurements evaluate the same feature. In our study, no correlations between the two parameters greater than 0.54 were found. Other authors have found similar correlations between these measures when evaluating Lenke 1 and 2 curves [
9]. This low correlation cannot be attributed to the reliability of the parameters evaluated if we consider that in all works published the reliability of the photographic measurements is excellent [
6],[
11] and the same occurs with radiological measurements [
5]. It is possible that the photographic measurements differ from radiological measurements because of the effect of the soft tissues in the shoulder area. It is obvious that the radiological and clinical balance of the shoulders are not an exact reflection of each other as suggested by Qiu et al. [
6]; we need to evaluate both factors when analyzing shoulder balance in patients with scoliosis, not just on the Lenke 2 curves but also for all kinds of curves.
T1-tilt moderately correlates with the photographic parameters (SHA, AHA, LRTA). Therefore, shoulder position cannot be inferred from a T1 value. In fact, there is a percentage of patients in whom shoulder and T1 tilt are in opposite directions [
24]. Other authors have found that the correlation of this measure with shoulder balance, both radiological [
23] and clinical [
18],[
21] is lower than for other measures such as CA or CRID. Bearing in mind that T1 is often the upper end vertebrae of the PTC and that the magnitude of the PTC is unrelated to ShB, our data indicate that T1 tilt should be the criterion to determine the structural nature of the PTC and its impact on ShB.
SHA can be considered the standard parameter to evaluate ShB in clinical photography. There is suitable intra and inter-observer reliability although the correlation with its radiographic equivalent is less than desirable. AHA is also a reliable measure but has a low correlation with radiological ShB. It is interesting to note the moderate correlation with the magnitude and tilt of the end vertebrae of the MTC which would suggest that this would be a parameter more related to deformity of the trunk than ShB. As we have pointed out above, this parameter was introduced to explore the possibility of having an alternative measure to SHA. The lack of concordance between both measures has led us to rule out this possibility. The possibility that LRTA would enable evaluating PTC led us to introduce this parameter into the analysis. In spite of correct reliability, this only shows a poor correlation with CRIA and T1 and no correlation with PTC. Although other authors have suggested that asymmetry in the trapezium area is a parameter to consider when clinically evaluating the shoulder area [
12], according to our results, this is a parameter that does not provide information for SHA and AHA. Consequently, we do not believe that it makes sense to recommend use of this parameter in clinical practice.
Shortcomings
In our opinion this study presents several significant limitations. First, our study did not include analysis of the photographic parameters in relation to the scoliosis pattern. Some authors [
11] have suggested that the photographic parameters could be different according to the type of curve. This possibility should be analyzed in further detail in future investigations. Second, we have not correlated ShB and axial plane deformity (angle of trunk inclination or apical vertebrae rotation); we take this decision due to the low reliability of radiographic measures used for this purpose [
25]. Third, a single photograph evaluated by different observers on two occasions was used for the reliability analysis. However, the reliability of this shot was not determined. Patients were placed on floor marks and they were asked to stay in a comfortable position. We think that this methodology was sufficient to guarantee repeating the photograph. However, we cannot determine the error of measurement related to the patient’s position. Fortin et al. found significant reliability of a photography technique similar to that used in our investigation [
10],[
19].