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BJPT 30 1---7 ARTICLE IN PRESS

1 Brazilian Journal of Physical Therapy (2017) xxx, xxx---xxx
2

3 Brazilian Journal of
Physical Therapy
https://www.journals.elsevier.com/brazilian-journal-of-physical-therapy

ORIGINAL RESEARCH

4 Reliability and validity of active and passive pectoralis

5 minor muscle length measures
6 Q1 Margaret Finley , Noel Goodstadt, Daniel Soler, Kristin Somerville, Zachary Friedman,
7 David Ebaugh

8 Department of Physical Therapy and Rehabilitation Science, Drexel University, Philadelphia, PA, USA

9 Received 12 May 2016; received in revised form 22 August 2016; accepted 15 September 2016

10 KEYWORDS Abstract
11 Shoulder; Background: Pectoralis minor muscle length is believed to play an important role in shoulder
12 Muscle length; pain and dysfunction. Current clinical procedures for assessing pectoralis minor muscle length
13 Rehabilitation may not provide the most useful information for clinical decision making.
14 Objective: To establish the reliability and construct validity of a novel technique to measure
15 pectoralis minor muscle length under actively and passively lengthened conditions.
16 Design: Cross-sectional repeated measures.
17 Methods: Thirty-four healthy adults (age: 23.9, SD = 1.6 years; 18 females) participated in this
18 study. Pectoralis minor muscle length was measured on the dominant arm in three length con-
19 ditions: resting, actively lengthened, and passively lengthened. Based upon availability, two
20 raters, out of a pool of ve, used a caliper to measure the distance between the coracoid pro-
21 cess and the 4th rib. The average of two pectoralis minor muscle length measures was used
22 for all muscle length conditions and analyses. Intraclass correlation coefcients determined
23 intra-and inter-rater reliability, and measurement error was determined via standard error of
24 measurement and minimal detectable change. Construct validity was assessed by ANOVA to
25 determine differences in muscle length across the three conditions.
26 Results: Our intra- and inter-rater reliability values across all three conditions ranged from
27 0.84 to 0.92 and from 0.80 to 0.90, respectively. Signicant differences (p < 0.001) in muscle
28 length were found among all three conditions: rest-active (3.66; SD = 1.36 cm), rest-passive
29 (4.72, SD = 1.41 cm), and active-passive (1.06, SD = 0.47 cm).
30 Conclusions: The techniques described in this study for measuring pectoralis minor muscle
31 length under resting and actively and passively lengthened conditions have acceptable reli-
32 ability for clinical decision making.
33 2017 Associacao Brasileira de Pesquisa e Pos-Graduacao em Fisioterapia. Published by Elsevier
34 Editora Ltda. All rights reserved.

35
Corresponding author at: Department of Physical Therapy & Rehabilitation Science, Drexel University, Three Parkway Building, 1601

Cherry Street, Mail Stop 7-502, Ofce 763, Philadelphia, PA 19102, USA.
E-mail: maf378@drexel.edu (M. Finley).
http://dx.doi.org/10.1016/j.bjpt.2017.04.004
1413-3555/ 2017 Associacao Brasileira de Pesquisa e Pos-Graduacao em Fisioterapia. Published by Elsevier Editora Ltda. All rights reserved.

Please cite this article in press as: Finley M, et al. Reliability and validity of active and passive pectoralis minor muscle
BJPT 30 1---7
length measures. Braz J Phys Ther. (2017), http://dx.doi.org/10.1016/j.bjpt.2017.04.004
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2 M. Finley et al.

36 Introduction length were then used to determine pectoralis minor muscle 97

extensibility. 98

37 Shoulder pain has been reported to affect up to 67%

38 of the general population across the lifetime.1 Rotator Methods 99
39 cuff disease is the most common cause of shoulder pain,
40 interferes with work and functional related activities,
41 and has a negative impact on health-related quality of
Study design 100

42 life.2---7
43 The alignment---impairment model has been proposed A cross-sectional, repeated-measures design was employed. 101

44 as a way to understand how multiple factors contribute

45 to the development of shoulder pain and dysfunction.8,9 Participants 102

46 This model describes how alignment deviations give rise to Participants were recruited from a university campus by per- 103

47 structural alterations, which then lead to pathomechanical sonal contact and advertisements. Individuals were eligible 104

48 alterations and development of shoulder pain. The model to participate if they were between 18 and 35 years of age, 105

49 proposes that several factors contribute to resting scapu- free of current shoulder pain, and able to elevate their arms 106

50 lar alignment, including the thoracic spine, shoulder girdle at least 130 . Individuals were excluded from participating 107

51 musculature, and tissue exibility. Persistent postures and if they self-reported any of the following: previously diag- 108

52 repetitive activities that place the shoulder in a protracted nosed scoliosis; a current episode of cervical or lumbar spine 109

53 position are believed to result in adaptive muscle short- pain; shoulder, elbow, forearm, wrist, or hand pain; brachial 110

54 ening, which may contribute to malalignment, pain, and plexus injury; or nerve palsy affecting the shoulder girdle or 111

55 ultimately movement dysfunction.8---10 Collectively, these upper extremity. Thirty-ve participants (female = 18) met 112

56 impairments are believed to lead to development of shoul- the criteria and were enrolled in the study. 113

57 der pain and dysfunction.8,11---15

58 The pectoralis minor muscle is believed to play an impor-
Ethical approval statement 114
59 tant role in shoulder girdle alignment and movement.16
60 The relationship between resting pectoralis minor muscle
61 length and scapulothoracic movement has been studied in All participants signed an informed consent, approved by 115

62 a healthy, young population.11,12,17 Individuals with shorter the Drexel University Institutional Review Board (Protocol # 116

63 resting pectoralis minor muscle length have been shown to 1408003050), Philadelphia, PA, USA, prior to beginning study 117

64 have reduced scapular upward rotation and scapular poste- procedures. 118

65 rior tilting during humeral elevation.11 The signicance of

66 this information is that these motion patterns are similar to Raters 119
67 those reported in individuals with shoulder pain secondary
68 to subacromial impingement,14 rotator cuff disease, and Five raters (two licensed physical therapists and three 120
69 glenohumeral instability.18,19 Based on this, clinical assess- nal year physical therapy students) underwent an approx- 121
70 ment of resting scapular alignment and pectoralis minor imately 90-min measurement procedure training session. 122
71 muscle length is widely performed as part of a physical This session consisted of reviewing the measurement proce- 123
72 therapy examination for individuals with shoulder pain and dures and having each rater practice on one another until all 124
73 dysfunction.16 raters felt comfortable performing all measurements. Rater 125
74 While resting pectoralis minor muscle length appears to selection for all participant measurement sessions was based 126
75 provide potentially useful information about scapular align- upon rater availability. All raters contributed to data col- 127
76 ment and scapulothoracic motion, it does not provide all lection sessions, and an attempt was made to balance the 128
77 of the necessary information for determining how much the number of measurement sessions among raters. 129
78 muscle can lengthen (muscle extensibility). In light of the
79 fact that a modeling study has shown that the pectoralis
80 minor muscle elongates up to 67% of its initial length dur- Study procedures 130

81 ing overhead arm motions,20 information about pectoralis

82 minor muscle extensibility could provide further clinical Pectoralis minor muscle length 131

83 insight into the inuence of this muscle on scapulothoracic Pectoralis minor muscle length was dened as the distance 132

84 motion.9,10,21 However, determining pectoralis minor muscle between two bony landmarks: the coracoid process and the 133

85 extensibility requires a valid and reliable method for mea- inferior medial aspect of the 4th rib adjacent to the ster- 134

86 suring pectoralis minor muscle length when the muscle is in nocostal junction. Initial landmark identication occurred 135

87 a lengthened position. with the participant supine where the landmarks were pal- 136

88 Therefore, the purposes of this study were to establish pated and marked with a dark marker. Landmark location 137

89 the rater reliability and construct validity of our technique was reassessed while the participant stood in their natural 138

90 for measuring pectoralis minor muscle length under actively relaxed posture and any necessary adjustments in landmark 139

91 and passively lengthened conditions. It was hypothesized location were made (Fig. 1A). In an attempt to minimize the 140

92 that our proposed technique would demonstrate good rel- inuence of anterior chest wall soft tissue mass on pectoralis 141

93 ative and absolute reliability and result in a signicant minor muscle length measures, we used a caliper (palpa- 142

94 increase in pectoralis minor muscle length as compared tion meter --- PALM) rather than a tape measure. To prevent 143

95 to the resting length, thereby establishing the validity of bias and to mask the rater, for all measures the PALM was 144

96 the technique. These measures of pectoralis minor muscle placed with the meter facing away from the rater. A second 145

Please cite this article in press as: Finley M, et al. Reliability and validity of active and passive pectoralis minor muscle
BJPT 30 1---7
length measures. Braz J Phys Ther. (2017), http://dx.doi.org/10.1016/j.bjpt.2017.04.004
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Active and passive pectoralis minor length 3

Figure 1 Pectoralis minor muscle length measurement technique. (A) Identication of anatomical landmarks (4th rib and coracoid
process); (B) caliper (PALM) measurement of pectoralis minor muscle length in resting position.

146 examiner read the caliper dial, recorded the length mea- one rater was asked to take a second set of measures on 185

147 surement, and returned the caliper to the zero position. All this subset of participants at the end of the data collec- 186

148 measurements were repeated twice. Following the standard tion session. As noted above, an alcohol swab was used to 187

149 procedure for obtaining pectoralis minor muscle length in remove all markings between the measurements used for 188

150 our clinic, if these measures differed by more than 0.50 cm, establishing intra-rater reliability. 189

151 the measure was repeated until two measures were within
152 0.50 cm of one another. These two measures were then aver-
153 aged, and the averaged value was used for all subsequent
154 analyses. Analyses 190

155 Resting pectoralis minor muscle length was measured

156 while participants stood in their relaxed natural posture Rater reliability 191

157 (Fig. 1B). Following resting measures, pectoralis minor mus- Intraclass correlation coefcients (ICC) were used to deter- 192

158 cle length was measured during actively and passively mine relative inter- and intra-rater reliability of pectoralis 193

159 lengthened conditions, with order randomly determined. minor muscle length measures for each muscle length 194

160 Bony landmarks were re-palpated and re-marked for meas- condition. Specically, the ICC(2,2) model was used to 195

161 ures taken in the lengthened conditions. The actively determine inter-rater reliability, while the ICC(3,2) model 196

162 lengthened condition required participants to maximally was used to determine intra-rater reliability.23 For the pur- 197

163 elevate and retract their scapula (Fig. 2). For the pas- poses of our study, intra- and inter-rater reliability were 198

164 sively lengthened condition, participants arms were placed dened as excellent (ICC > 0.80), good (ICC = 0.61---0.80), and 199

165 in approximately 30 of exion. While stabilizing the par- fair (ICC = 0.41---0.60).23 Absolute reliability, which provides 200

166 ticipants trunk, a clinician used the distal end of the information related to measurement error, was determined 201

167 participants humerus to push their shoulder in a supe- by the standard error of the measurement (SEM) and min- 202

168 rior/posterior direction until rm tissue resistance was imal detectable change (MDC95) for inter- and intra-rater 203

169 encountered (Fig. 3). Our lengthening techniques were and each pectoralis minor muscle length condition. 204

170 based upon a cadaveric study by Muraki et al. that inves-

171 tigated appropriate stretching techniques for the pectoralis
172 minor muscle.22
Construct validity 205

A one-way repeated measure ANOVA determined if dif- 206

ferences in pectoralis minor muscle length existed among 207

173 Rater reliability the resting, actively lengthened, and passively lengthened 208

conditions. Bonferroni post hoc analyses were used to deter- 209

174 Inter-rater reliability of pectoralis minor muscle length mine specic pairwise differences while controlling for Type 210
175 measures for all three conditions (resting, actively length- I error. The level of signicance was set at 0.05. 211
176 ened, and passively lengthened) was determined by
177 independent measures performed by two raters. Once raters
178 were identied, the order in which they took measure-
179 ments was randomly determined. After the rst rater Pectoralis minor muscle extensibility 212

180 completed their measurements, markings were removed Pectoralis minor muscle extensibility was determined 213

181 with an alcohol swab and the second rater completed their from the active and passive length conditions as follows: 214

182 measurements. active condition = [(active length resting length)/resting 215

183 Intra-rater reliability was determined from a random sub- length] * 100, and passive condition = [(passive 216

184 set of 20 participants. Once again, based upon availability, length resting length)/resting length] * 100. 217

Please cite this article in press as: Finley M, et al. Reliability and validity of active and passive pectoralis minor muscle
BJPT 30 1---7
length measures. Braz J Phys Ther. (2017), http://dx.doi.org/10.1016/j.bjpt.2017.04.004
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4 M. Finley et al.

Figure 2 Pectoralis minor muscle active lengthening technique. (A) Maximal scapular elevation; (B) maximal scapular adduction.

Figure 3 Pectoralis minor muscle passive lengthening technique. (A) Starting position of 30 humeral exion; (B) superior/posterior
translational force by examiner.

218 Results 2.05 cm, respectively. The ICC, SEM, and MDC95 for our 229

inter-rater measurements range from 0.80 to 0.90, 0.57 to 230

219 Thirty-ve individuals participated in the study. How- 0.87 cm, 1.58 to 2.42 cm, respectively (Table 1). 231

220 ever, data from one participant was omitted due to a

221 pectoralis minor muscle length recording error. Data from
Construct validity 232
222 the dominant arm of 34 participants were included in the
223 analysis (mean age = 23.9, SD = 1.6 years, height = 168.9,
Mauchlys test indicated that the assumption of 233
224 SD = 1.6 8.9 cm, weight = 68.1, SD = 1.6 14.1 kg, right hand
sphericity had been violated [X2 (2) = 38.5, p < 0.001]. 234
225 dominance = 30).
Therefore, degrees of freedom were corrected with a 235

Greenhouse---Geisser estimate of sphericity ( = 0.59). 236

226 Rater reliability Pectoralis minor muscle length was 16.31, SD = 1.6 1.64 cm 237

for resting, 19.97, SD = 1.6 1.92 cm for actively lengthened, 238

227 The ICC, SEM, and MDC95 for our intra-rater measurements and 21.03 1.94 cm for the passively lengthened condition. 239

228 range from 0.84 to 0.92, 0.45 to 0.74 cm, and 1.85 to Results showed a signicant difference among all three 240

Please cite this article in press as: Finley M, et al. Reliability and validity of active and passive pectoralis minor muscle
BJPT 30 1---7
length measures. Braz J Phys Ther. (2017), http://dx.doi.org/10.1016/j.bjpt.2017.04.004
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Active and passive pectoralis minor length 5

Table 1 Relative and absolute reliability for pectoralis minor muscle length-3 conditions.
Condition n Relative reliability Absolute reliability MDC95 (cm)
ICC (95% CI) SEM (cm)
Resting
Intra-rater 20 ICC(3,2) = 0.92(0.79---0.97) 0.45 1.25
Inter-rater 34 ICC(2,2) = 0.90(0.81---0.95) 0.57 1.58
Active
Intra-rater 20 ICC(3,2) = 0.85(0.61---0.94) 0.66 1.83
Inter-rater 34 ICC(2,2) = 0.80(0.61---0.90) 0.87 2.42
Passive
Intra-rater 20 ICC(3,2) = 0.84(0.60---0.94) 0.74 2.05
Inter-rater 34 ICC(2,2) = 0.81(0.62---0.91) 0.85 2.36

241 length conditions [F(1.2,38.8) = 354.2, p < 0.001]. Post 95% condence intervals indicate good to excellent inter- 280

242 hoc pairwise comparisons revealed signicant differences rater reliability and fair to excellent intra-rater reliability. 281

243 between rest-active conditions (3.66, SD = 1.6 1.36 cm, The signicant changes in pectoralis minor muscle length 282

244 p < 0.001), rest-passive conditions (4.72, SD = 1.6 1.41 cm, across muscle length conditions provides data to support 283

245 p < 0.000), and active-passive conditions (1.06, SD = 1.6 the construct validity of our procedures for actively and 284

246 0.47 cm, p < 0.001). passively lengthening the muscle. During the active and pas- 285

sive lengthened conditions, there was an averaged increase 286

in pectoralis minor muscle length, beyond resting length, 287

of 3.66 cm and 4.72 cm, respectively. Eighty-eight percent 288

247 Discussion (30/34) of measures exceeded our MDC95 values for the 289

active condition (1.83 cm) and 97% (33/34) exceeded the 290

248 In order to make sound clinical decisions, health care passive condition (2.05 cm), which indicates a true change 291

249 providers should know the psychometric properties of the in muscle length. Although a signicant difference was noted 292

250 measures they choose to collect on their patients.24 Ade- in muscle length between the active and passive conditions, 293

251 quate relative and absolute reliability are two essential this difference was small (1.06 cm) and within our measure- 294

252 psychometric properties of any measurement intended for ment error. 295

253 clinical decision making. The ndings from our study demon- We believe the ndings from our study provide clini- 296

254 strate that our method of measuring pectoralis minor muscle cians with a reliable procedure for obtaining measures of 297

255 length in a resting position, as well as when the muscle was pectoralis minor muscle length, which can then be used 298

256 actively and passively lengthened, has acceptable intra- and to determine muscle extensibility. While a tight or short- 299

257 inter-rater reliability for use in clinical settings. ened pectoralis minor muscle has been theorized to play 300

258 Our intra-rater reliability values for resting pec- an important role in the development of shoulder pain 301

259 toralis minor muscle length (ICC(3,2) = 0.92, SEM = 0.45 cm, and dysfunction, information about pectoralis minor mus- 302

260 MDC95 = 1.25 cm) are very similar to those previously cle extensibility and what constitutes a shortened pectoralis 303

261 reported (Table 2).25,26 As noted in Table 2, our 95% con- minor muscle is currently unknown.12,16 Although Borstad has 304

262 dence intervals indicate good to excellent reliability for provided information about typical resting pectoralis minor 305

263 measuring resting pectoralis minor muscle length. Col- muscle length and cut points for dening shorter and longer 306

264 lectively, these ndings demonstrate excellent intra- and resting muscle lengths, these values do not provide infor- 307

265 inter-rater reliability, with small measurement error, when mation about whether or not the pectoralis minor muscle is 308

266 using a caliper or tape measure to measure resting pectoralis shortened.11,17 Participants in our study demonstrated, on 309

267 minor muscle length. However, a resting measurement of average, a 22.4% and 29% increase in pectoralis minor mus- 310

268 muscle length only provides part of the information needed cle length during the actively and passively lengthened 311

269 to determine muscle extensibility. conditions when compared to the resting position. This infor- 312

270 To the best of our knowledge, we are the rst to report mation may be viewed as a starting point for dening normal 313

271 intra- and inter-rater reliability for measures of pectoralis pectoralis minor muscle extensibility, as well as what con- 314

272 minor muscle length under actively and passively lengthened stitutes a shortened muscle. 315

273 conditions. The ICC, SEM, and MDC95 for our measurements The information provided by the active and passive 316

274 ranged from 0.80---0.85, 0.66---0.87 cm, and 1.83---2.42 cm, length conditions may also be useful to clinicians for select- 317

275 respectively. As noted in Table 2, our 95% condence ing exercises intended to stretch the pectoralis minor 318

276 intervals indicate good to excellent intra- and inter-rater muscle. While the optimal stretch has yet to be dened, 319

277 reliability for measures of pectoralis minor muscle length Borstad and Ludewig12 reported that the unilateral corner 320

278 under actively lengthened conditions. For measures of pec- stretch was more effective for elongating the pectoralis 321

279 toralis minor muscle length under passive conditions, our minor muscle than a supine manual or sitting manual 322

Please cite this article in press as: Finley M, et al. Reliability and validity of active and passive pectoralis minor muscle
BJPT 30 1---7
length measures. Braz J Phys Ther. (2017), http://dx.doi.org/10.1016/j.bjpt.2017.04.004
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6 M. Finley et al.

Table 2 Comparison of reliability studies for measuring resting pectoralis minor muscle length.
Sample ICC SEM (cm) MDC95 (cm)
Intra-rater reliability
Current study ICC(3,2) Asymptomatic 0.92 0.45 1.25
Rosa et al.26 ICC(3,1) Asymptomatic 0.95 0.40 1.13
Symptomatic 0.95 0.41 1.14
Rondeau et al.24 Dominant side 0.98 0.32 ---
ICC(2,k) Non-dominant side 0.99 0.29 ---
Inter-rater reliability
Current study ICC(2,2) Asymptomatic 0.90 0.51 1.58
Rosa et al.26 ICC(3,2) Asymptomatic 0.86 0.70 ---
Symptomatic 0.87 0.84 ---
ICC, intraclass correlation coefcient; SEM, standard error of measurement; MDC, minimal detectable change.

323 stretch.12 The mean pectoralis minor muscle length change length measurement error (1.25 cm).28 One possible expla- 366

324 during the corner stretch for the 50 healthy participants in nation for why larger changes in resting pectoralis minor 367

325 Borstad and Ludewigs12 study was 2.24 cm. The mean mus- muscle length were not found in their study is that perhaps 368

326 cle length changes for the active and passive conditions in none of the participants in their study had a shortened pec- 369

327 the current study were 3.66 cm and 4.72 cm, respectively. toralis minor muscle prior to the stretching. This further 370

328 These ndings suggest that the procedures described in this supports the construct that measures of resting pectoralis 371

329 study for actively or passively lengthening the pectoralis minor muscle length do not provide adequate information 372

330 minor muscle may be more effective than a unilateral cor- for determining if the muscle is shortened. 373

331 ner stretch. Although a caliper was used in our study to

332 measure pectoralis minor muscle length and an electromag-
333 netic tracking system was used in Borstad and Ludewigs12
334 study, both studies used the same bony landmarks as a refer-
335 ence for their muscle length measures, and each instrument Limitations 374

336 measured the linear distance between those landmarks.12

337 While the pectoralis minor muscle is lengthened during the The fact that all of the participants in the current study 375

338 corner stretch, lengthening of the pectoralis major muscle were young and not experiencing shoulder pain is a poten- 376

339 also likely occurs during this stretch.27 This may explain why tial limitation of the study. While further studies are needed 377

340 the muscle length change reported by Borstad and Ludewig12 to investigate the reliability of these measures in individ- 378

341 is smaller than our active and passive muscle length changes. uals with current shoulder pain, we believe our ndings 379

342 As reported previously, our procedures for lengthening the provide a foundation upon which further studies can build. 380

343 pectoralis minor muscle were based on a cadaveric study Other potential limitations are the use of two examiners 381

344 by Muraki et al.22 In their study, displacement sensors were to obtain muscle length measures during the passive condi- 382

345 directly attached to the pectoralis minor muscles in nine tion and our criteria for what constituted two acceptable 383

346 cadaveric specimens. These sensors measured muscle length repeated measures (within 0.5 cm of one another). While 384

347 changes during three different stretches (scapular retrac- we acknowledge the fact that requiring two examiners to 385

348 tion at 0 and 30 of exion and horizontal abduction with perform the passive assessment may not be practical in 386

349 the arm in 90 of abduction and external rotation). Findings a busy clinic setting, this is in line with what has been 387

350 from their study revealed the greatest change in pectoralis described for obtaining measures of shoulder internal rota- 388

351 minor muscle length during the scapular retraction at 30 of tion range of motion measures.29,30 It should be noted that 389

352 exion stretch.22 differences in muscle length change between the active 390

353 We are aware of one study that has investigated and passive conditions were small and insignicant. This 391

354 the immediate effect of pectoralis minor muscle stretch- would indicate that active measures of pectoralis minor 392

355 ing on pectoralis minor muscle length. Williams et al.28 muscle length may provide adequate information that could 393

356 demonstrated a statistically signicant increase in resting then be used to determine pectoralis minor muscle extensi- 394

357 pectoralis minor muscle length (distance between coracoid bility. Obviously, if additional information about pectoralis 395

358 process and 4th rib measured via a tape measure) fol- minor muscle extensibility that may be gathered via the end 396

359 lowing two repetitions of a horizontal abduction stretch feel is desired, then a second examiner may be benecial. 397

360 (supine, shoulder in 90 of abduction and external rota- Concerning our criteria for two acceptable measures, the 398

361 tion, overpressure applied into horizontal abduction). Their maximum number of measures on any participant needed 399

362 reported average change in resting muscle length of 0.6 cm to satisfy our criteria (two measures within 0.5 cm of one 400

363 is small and of questionable clinical signicance. Although another) was three. This additional time needed to acquire 401

364 not reported by Williams et al., this small change in res- a third measure would not be a major limitation, even in a 402

365 ting muscle length falls within our intra-rater resting muscle busy clinic. 403

Please cite this article in press as: Finley M, et al. Reliability and validity of active and passive pectoralis minor muscle
BJPT 30 1---7
length measures. Braz J Phys Ther. (2017), http://dx.doi.org/10.1016/j.bjpt.2017.04.004
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Active and passive pectoralis minor length 7

404 Conclusions 11. Borstad JD, Ludewig PM. The effect of long versus short pec- 456
toralis minor resting length on scapular kinematics in healthy 457
individuals. J Orthop Sports Phys Ther. 2005;35(4):227---238. 458
405 In conclusion, the procedures described in this study for
12. Borstad JD, Ludewig PM. Comparison of three stretches 459
406 measuring pectoralis minor muscle length under resting, for the pectoralis minor muscle. J Shoulder Elbow Surg. 460
407 actively lengthened, and passively lengthened conditions 2006;15(3):324---330. 461
408 have acceptable reliability for clinical decision making. 13. Hebert LJ, Moffet H, McFadyen BJ, Dionne CE. Scapular behav- 462
409 Additionally, the active and passive lengthening procedures ior in shoulder impingement syndrome. Arch Phys Med Rehabil. 463
410 resulted in great changes in pectoralis minor muscle length. 2002;83(1):60---69. 464

411 Collectively, this information can be used to inform future 14. Ludewig PM, Cook TM. Alterations in shoulder kinematics and 465

412 studies designed to determine an operational denition for associated muscle activity in people with symptoms of shoulder 466

413 shortened pectoralis minor muscle and to establish optimal impingement. Phys Ther. 2000;80(3):276---291. 467

414 stretches for restoring pectoralis minor muscle length. 15. Lukasiewicz AC, McClure P, Michener L, Pratt N, Sennett B. 468
Comparison of 3-dimensional scapular position and orientation 469
between subjects with and without shoulder impingement. J 470
415 Ethical approval Orthop Sports Phys Ther. 1999;29(10):574---583, discussion 584- 471
576. 472

416 Drexel University Institutional Review Board, Protocol # 16. Morais N, Cruz J. The pectoralis minor muscle and shoulder 473

417 1408003050. movement-related impairments and pain: rationale, assess- 474

ment and management. Phys Ther Sport. 2016;17:1---13. 475
17. Borstad JD. Measurement of pectoralis minor muscle length: 476
418 Funding validation and clinical application. J Orthop Sports Phys Ther. 477
2008;38(4):169---174. 478

419 This research did not receive any specic grant from funding 18. Kibler WB, Ludewig PM, McClure P, Uhl TL, Sciascia A. Scapu- 479

420 agencies in the public, commercial, or not-for-prot sectors. lar Summit 2009: introduction. J Orthop Sports Phys Ther. 480
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421 Conict of interest ics and glenohumeral joint pathologies. J Orthop Sports Phys 483
Ther. 2009;39(2):90---104. 484

422 The authors declare no conicts of interest. 20. Van der Helm FC. Analysis of the kinematic and dynamic 485
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Please cite this article in press as: Finley M, et al. Reliability and validity of active and passive pectoralis minor muscle
BJPT 30 1---7
length measures. Braz J Phys Ther. (2017), http://dx.doi.org/10.1016/j.bjpt.2017.04.004