Overview:

There are currently no standard examination positions for flexion and extension of the shoulder. During the movements of the gleno-humeral joint there are always relative movements within the scapulo-thoracic junction. These are usually described as fitting a set of established normal patterns. These must be considered when testing the shoulder. When testing or exercising the shoulder it is vital that the subject has sufficient warm up before performing any movements.

 

These movements can be performed in either the lying, standing or seated positions.  

 

Lying position:

 

The most stabilised position for testing flexion but it limits extension unless the subject can get very close to the edge of the bed. Best for research.

 

shoulderflexlying

To view a set up video see below

Standing position:

 

In the standing position (see below) stabilization is difficult if not impossible (and probably undesirable). Testing in this position is more functional than that in the seated position.

 

shoulderflexstanding

 Seated position:

 

Alignment is the same as that for the standing position but stabilization usually involves thoracic strapping (see below). Although this position is not as functional. Best for patients.

 

shoulderflexseated

Stabilisation:

Lying: In the lying position stabilisation normally only involves a pelvic strap to prevent the torso from influencing the results.

Standing: Stabilistion in the standing position is not normally required as this is the most functional position.

Seated: in the seated position stabilisation usually involves a lap belt and chest straps.

Attachments:

There is validity in using a wrist strap (as seen in seated above) rather than a grip handle (as seen in lying above) because this eliminates the influence of the wrist flexors and extensors. Although this may have some face validity it does not translate into real world testing. The hand grip is then always preferable.

Make sure the elbow has a small degree of flexion throughout the range to ensure it's safety (5 degrees is usually enough).

Axis of rotation:

Regardless of the position of the test the alignment of the instantaneous axis of rotation should be a point roughly 2-3 cms below the inferior lip of the acromial arch. But it has been shown by Walmsley (1993) that the gleno-humeral joint as a whole (never mind its instantaneous axis of rotation) moves by an average of 8cm through range so the need for accuracy must be questioned. 

Anatomical zero:

With arm by side of body.

Range of motion:

Generally a large range of motion is chosen for these tests. Generally 0 degrees to 160 and in some cases 180 degrees flexion have been used. Extension is tested less often (most researchers use extension from flexion), however anything from 0-40/60 degrees can be used.

Some testers will test the first 60-90 degrees of flexion with one axis then the remaining motion (which could be described as elevation anyway) with a different axis. 

Gravity correction:

As the lever arm can be very long and heavy in these movements setting of gravity correction is essential. In patients gravity elimination (Humac Norm) can be very beneficial to reduce ballistic forces.

Speeds:

 

As velocities in some sports (any involving throwing an object) are known to reach thousands of degrees/second (Pappas et al., 1985) testing using a dynamometer been said to be non-functional. However, speeds over 300 degrees/second have been found to be difficult to achieve by even baseball pitchers (Cook et al., 1987). This could be said to suggest that muscular effort starts the motion but only occurs at slower speeds with momentum and acceleration playing a larger role later in the speed of the motion later through range rather than pure strength. Even if this speed could be achieved it is over such a small arc that the results gained would likely be fruitless.

 

Generally it is accepted that speeds of 60 degrees/second and multiples of this should be used.

Shoulder Flexion / Extension Protocols:

Muscles involved:

        Anterior deltoid, biceps and posterior deltoid, latissimus dorsi 

 

Strength Test Protocols General Patients Athletes Research
Contraction Cycle con/con con/con 

con/con

con/ecc 

con/con

ecc/ecc

Speed/s 60 or 120 60 or 120 60-300 60-500
Trial Repetitions 0 0 3
Repetitions 10 10  10 5
Sets 3 4 up to 9
Rest between sets 20-30 secs 20-30 secs  20-30 secs 20 secs
Rest between speeds 2 minutes 2 minutes

2 minutes 

2-5 minutes
Rest between sides 5 minutes 5 minutes 

5 minutes 

5 minutes 
Feedback  nil nil  nil  nil 

 

Endurance Test Protocols General Patients Athletes Research
Contraction Cycle con/con con/con 

con/con

con/ecc 

con/con

ecc/ecc

Speed/s 120 120 120-300 120-500
Trial Repetitions 0 0 0
Repetitions Max Max Max Max
Sets 1 1 1
Rest between sets N\A N/A N/A N/A
Rest between speeds 10-15 mins 10-15 mins  10-15 mins 10-30 mins
Rest between sides 5 mins 5 mins  5 mins  5 mins 
Feedback  nil nil  nil  nil 

 

Strength Exercise Protocol General Patients Athletes
Contraction Cycle con/con con/con con/ecc
Speed/s 60 up to 180 60 up to 180 60-300
Trial Repetitions 0 0 0
Repetitions 10 10 14
Sets 6 6 up to 12
Rest between sets 30-60 secs 30-60 secs 30 secs
Rest between speeds 2 mins 2 mins 2 mins 
Rest between sides Nil Nil Nil 
Feedback bar bar bar

 

Endurance Exercise Protocol General Patients Athletes
Contraction Cycle con/con con/con con/con
Speed/s 120-180 120-180 120-300
Trial Repetitions 0 0 0
Repetitions Max Max Max
Sets 1-3 1 1-3
Rest between sets 5-10 mins N/A 5-10 mins
Rest between speeds 10-30 mins N/A 10-30 mins 
Rest between sides Nil Nil Nil
Feedback bar/pie chart bar/pie chart bar/pie chart

 

Notes:

Test the uninvolved or dominant limb first.  Flexion beyond 900 produces high variability in results.

 

Interpretation:

In the shoulder it is normal to look at the ratio between the right and left sides there should be a 0-10% difference between the sides. Anything beyond this would either demonstrate extreme hand dominance (this can happen in certain sports like javelin), or indicate a muscle imbalance which would be best corrected.

Eccentric results are generally 30% higher than concentric within the same muscle.

Angle of peak torque for flexion is -30 degrees although this can vary as much as 40% (that is 30 degrees in extension) (Bober et al 2002)

Angle of peak torque for extension 90 degrees although this can vary as much as 40% (that is 90 degrees of flexion)  (bober et al 2002)

 

Frozen Shoulder or Non Specific Anterior Joint Capsulitis:

The curves seen will be erratic with a low coefficient of variance. These results are entirely due to pain.

Graph shown for flexion concentrically.

 frozenshouldermap

 

Normative values:

Berg et al. (1985) Age Sex Machine Nm mean (SD) Nm mean (SD)
speed deg/s 20-26 f Cybex Flexion Extension
60       34.5 44.5
120       31.9 40.2
180       28.7 34.2
240       23.7 29.1
           
Cahalan et al. (2001) 21-40 M/F Cybex    
60       48(11) 90 (21)
180       40 (10) 72 (16)
300       33 (11) 60 (16)
           
So et al. (1995)          
60 21 (2.1) M Cybex 47.9 (7.9) 66.7 (12.9)
240       33.2 (7.3) 44.5 (10.2
           
Khalaf & Parnianpour (2001) 26 (3.8) M Kin-Com    
10       69.9 (10.2) 92.7 (19.2)
50       58.6 (11.4) 86.1 (13.3)
100       43.7 (8.5) 73.2 (15.1)
150       39.1 (7.9) 66.5 (11.6)
200       36.8 (7.5) 58.2 (11.3)
250       34.4 (8.9) 53.3 (12.7)
  24 (2.4 F Kin-Com    
10       30.9 (7.7) 43 (10)
50       24.8 (8.3) 43 (10)
100       18.4 (5.2) 34.4 (9)
150       16 (5) 29.99 (10.2)
200       13.7 (4.2) 22.6 (6.2)
250       12.3 (3) 20.4 (8.7)
           
Biodex Values N/A M Biodex PTBW Goal PTBW Goal
60       75-101 83-110
180       66-86 66-89
300       27-36 83-110
    F      
60       69-89 72-92
180       60-78 54-69
300       63-80 51-69

Values for flexor group concentric and eccentric strength (in Nm). Based on Ivey et al (1985), Cahalan et al (1991) and + Shkiar & Dvir (1994) sedentary subjects.

 

600/s

1200/sec

1800/sec

3000/sec

Concentric

       

Men

64

59

55

51

Women

32

35

31

25

Eccentric

       

Men

 

74

 

77

Women

 

44

 

47

Values for shoulder extensor group concentric and eccentric strength (in Nm). Based on Ivey et al (1985), Cahalan et al (1991) and + Shkiar & Dvir (1994) sedentary subjects.

 

600/s

1200/sec

1800/sec

3000/sec

Concentric

       

Men

100

83

84

79

Women

49

38

45

30

Eccentric

       

Men

 

112

 

113

Women

 

57

 

59

 Hughes et al (1999) looked at shoulder flexion/extension ratios between the dominant and non dominant sides:

angle of flexion

Dominant Side % (sd)

Non Dominant Side % (sd)

Average %
30 0.82 (0.21) 0.75 (0.21) 0.79 (0.16)
60 0.59 (0.17) 0.56 (0.20) 0.58 (0.16)
90 0.47 (0.19) 0.43 (0.15) 0.45 (0.14)