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Thoracic Hyperkyphosis and The Shoulder


Original Editor - Farah Elzanaty
Top Contributors - Farah Elzanaty, Vidya Acharya and Alexandra Stead

Introduction

Thoracic hyperkyphosis is an excessive antero-posterior curvature of the thoracic spine exceeding 40° as measured by the Cobb angle and is a common spinal deformity affecting an estimated 20–40% of community-dwelling older adults.[1][2] Hyperkyphosis significantly impacts multiple facets of physical function,[3] [2] which this article examines its specific effects on shoulder mechanics and function.

The altered spinal curvature associated with hyperkyphosis disrupts the normal resting position of the scapula and changes the mechanical environment of the glenohumeral joint.[4] This disruption predisposes individuals to a range of shoulder pathologies, including rotator cuff-related shoulder pain (RCRSP), subacromial pain syndrome (SPS), and adhesive capsulitis.[5][4]

A 2014 large-scale cross-sectional study of 2,144 participants aged over 40 years confirmed that thoracic kyphosis was independently associated with subacromial impingement syndrome, with scapular dyskinesis identified as the key mediating mechanism.[4] Despite this, the thoracic spine is frequently overlooked in shoulder rehabilitation and treating the shoulder in isolation without addressing the underlying postural drivers produces inferior long-term outcomes.[6]

Clinically Relevant Anatomy

The Thoracic Spine and Scapulothoracic Relationship

The scapula sits on the posterior thoracic wall and functions as the mobile base from which all glenohumeral movement occurs.[7] Its position and movement are directly shaped by the curvature of the thoracic spine beneath it.[8] In a person with hyperkyphosis, the increased thoracic flexion creates a posteriorly curved thoracic surface. This forces the scapula into a position of anterior tilt (tipping forward), downward rotation and internal rotation relative to the thorax.[9]

A 2024 study confirmed that round-shoulder posture (RSP) is characterised by protraction, downward rotation, anterior tilting and internal rotation of the scapula, all of which predispose the person to shoulder dysfunction.[9] This altered resting position shifts the glenoid fossa, inferiorly and anteriorly, reducing the mechanical advantage of the rotator cuff and narrowing the subacromial space available for the rotator cuff tendons during arm elevation.[5][4]

Scapulohumeral Rhythm

Scapulohumeral rhythm describes the coordinated motion between the glenohumeral and scapulothoracic articulation during arm elevation. In healthy individuals, the scapula progressively upwardly rotates, posteriorly tilts and externally rotates during arm elevation to maintain alignment of the glenoid beneath the humeral head throughout the movement arc.[8]

A 2025 systematic review and meta-regression of 20 studies using three-dimensional non-surface motion tracking confirmed that during arm elevation, the scapula moves immediately towards upward rotation and posterior tilt, with no initial setting phase as previously assumed.[8] There is significant individual variability in scapular kinematics in healthy individuals, which means physiotherapists should avoid labelling early scapular movement as dysfunctional.[8]

In people with hyperkyphosis, thoracic kyphosis reduces thoracic extension mobility, which is normally required for full arm elevation.[4] As a result, the scapula fails to achieve sufficient upward rotation and posterior tilt during arm elevation, reducing subacromial space and increasing the risk of soft tissue compression, pain and tendon damage.[4] [10]

Muscle Imbalance

Hyperkyphosis produces predictable patterns of muscle imbalance around the shoulder girdle. The pectoralis minor muscle becomes shortened, directly pulling the scapula into anterior tilt and downward rotation. A 2023 randomised comparative study confirmed that shortening of the pectoralis minor muscle adversely affects scapular movement and reduces shoulder flexion range of motion and that combined pectoralis minor stretching and lower trapezius strengthening produced significant correction of rounded shoulder posture and improved shoulder range of motion.[11]

Muscles that become lengthened and underactive in hyperkyphosis include:

  • Lower and middle trapezius, which are responsible for scapular depression, retraction, and upward rotation.
  • Serratus anterior, which is the primary driver of scapular upward rotation and posterior tilt during arm elevation.
  • Rhomboids, which are responsible for scapular retraction.

These muscle imbalances collectively disrupt scapulohumeral rhythm and compromise dynamic shoulder stability.[11][12]

The Subacromial Space

The subacromial space is the gap between the humeral head and the undersurface of the acromion. The rotator cuff tendons, subacromial bursa and the long head of biceps tendon pass through this space. When scapular kinematics are disrupted by hyperkyphosis, the subacromial space narrows during arm elevation, placing compressive stress on these structures and predisposing to tendinopathy, bursitis and rotator cuff tears.[4][10]

A 2026 randomised controlled trial directly measured the acromiohumeral distance (AHD) in 32 people with subacromial pain Syndrome (SPS) and hyperkyphosis. The thoracic mobilisation group demonstrated significantly greater improvements in AHD, thoracic kyphosis angle, pain intensity and shoulder function scores compared to the exercise-only group, confirming the direct relationship between thoracic posture and subacromial space dimensions.[10]

Clinical Presentation

Individuals with hyperkyphosis-related shoulder dysfunction present with a combination of postural, painful and functional features. These commonly include the following:

Postural features

A visibly rounded upper back with forward head posture, elevated and protracted shoulder girdles, anteriorly tilted scapulae and increased thoracic kyphosis angle on lateral view. These changes are often gradual and may initially go unnoticed.[1]

Pain

Anterior or lateral shoulder pain that may radiate into the upper arm. Pain is commonly reproduced during overhead activities, reaching behind the back or sustained arm elevation. At rest, it is often described as a dull ache, worsening with activity.[5] A 2023 cross-sectional study of 42 people with subacromial impingement syndrome found significantly impaired proprioception (joint position sense) in the affected shoulder compared to asymptomatic controls, and demonstrated moderate-to-strong correlations between proprioceptive deficit, pain intensity and functional disability.[13]

Reduced range of motion

Restriction in shoulder flexion, abduction and external rotation is common. A 2024 PROSPERO-registered systematic review and meta-analysis of 604 participants across 8 studies confirmed that people with rotator cuff related shoulder pain (RCRSP) demonstrate significantly reduced shoulder flexion, external rotation and elevated static thoracic kyphosis compared to asymptomatic controls.[5]

Scapular dyskinesis

Scapular dyskinesis (alteration in scapular position or motion during arm movement) is a clinically relevant finding. People may demonstrate insufficient upward rotation or posterior tilting during arm elevation, asymmetrical scapular elevation or winging of the medial scapular border.[8]

Muscle weakness

Weakness of the rotator cuff and scapular stabilisers, particularly the lower trapezius, serratus anterior, and external rotators, is a consistent finding and perpetuates the cycle of altered shoulder biomechanics.[11] [12]

Functional limitations

Difficulty with overhead tasks (reaching high shelves, dressing, hair care), occupational activities and sport activities requiring arm elevation. In older adults, activities of daily living are commonly impaired, contributing to reduced quality of life.[1]

Diagnostic Procedures

Diagnosis relies primarily on a structured clinical assessment comprising the following components:

  • Postural assessment in standing: Observing the thoracic spine from the lateral view to assess kyphotic curvature and from the posterior view to assess scapular position, symmetry and the presence of dyskinesis during arm elevation.
  • Thoracic kyphosis angle measurement using a validated clinical instrument. A 2025 systematic review and meta-analysis of 72 studies confirmed that the flexicurve angle, analogue inclinometer, photogrammetry and Spinal Mouse device all demonstrate valid and reliable correlation with the radiographic Cobb angle gold standard and are appropriate for clinical use.[14]
  • Active shoulder range of motion measured with a standard goniometer, for recording flexion, abduction, external rotation and internal rotation bilaterally.[5]
  • Scapular observation during arm elevation: assessing the pattern, symmetry and timing of scapular motion to identify dyskinesis.[8]
  • Muscle flexibility testing of the pectoralis minor, posterior shoulder capsule and cervical extensors to identify contributing tightness.[11]
  • Manual muscle testing of the rotator cuffs and the scapular stabilisers (lower trapezius, serratus anterior, external rotators).[12]
  • Provocative shoulder tests assist identification of specific shoulder pathologies. The Hawkins-Kennedy test, Neer’s sign, Empty Can Test also known as Jobe test and External Rotation Lag Sign help guide assessment of rotator cuff integrity. A 2023 cross-sectional study confirmed that shoulder proprioception testing using a digital inclinometer provides a reliable and clinically meaningful assessment of joint position sense deficits in people with subacromial impingement syndrome and that proprioceptive impairment correlated significantly with both pain and disability scores.[13] Proprioception assessment should therefore form part of the standard clinical assessment for this population.
  • Occiput to Wall distance (OWD): This simple, reproducible clinical measure requires the person to stand with their heels and back against a wall in their natural posture. The horizontal distance from the occiput to the wall is measured in centimetres. A positive measurement indicates clinically relevant thoracic hyperkyphosis and provides a practical method of monitoring change over time.[1]
  • Imaging: Plain radiography of the thoracic spine confirms the kyphosis angle via the modified Cobb angle method and identifies structural causes such as vertebral wedging or osteoporotic compression fractures.[1] Ultrasound imaging enables real-time assessment of the acromiohumeral distance and identification of rotator cuff tendon pathology.[10]

[15]

[16]

[17]

[18]

[19]


Outcome Measures

The following validated outcome measures are used to monitor progress in people with hyperkyphosis-related shoulder dysfunction.

  1. Shoulder Pain and Disability Index (SPADI): A 13-item patient-reported outcome measure comprising a five-item pain subscale and an eight-item disability subscale. A 2023 validation study in 124 people with frozen shoulder demonstrated satisfactory construct validity and internal consistency.[20][21] The SPADI is appropriate for use across shoulder conditions associated with postural dysfunction.
  2. Disabilities of the Arm, Shoulder and Hand questionnaire (DASH): Measures functional disability across the upper limb. Recommended when shoulder dysfunction impairs broader upper limb performance.[20][22]
  3. Numeric Pain Rating Scale (NPRS): An 11-point scale (0 = no pain; 10 = worst imaginable pain) assessing pain intensity at rest, during activity and overnight. Simple to administer, responsive to change, and validated for musculoskeletal shoulder conditions.[13][23]

Differential Diagnosis

The following conditions share overlapping features with hyperkyphosis-related shoulder dysfunction and should be considered during clinical assessment.

  • Cervical radiculopathy: Nerve root compression in the cervical spine produces arm pain, weakness, and paraesthesia, that may mimic rotator cuff pathology.[24] Cervical neurological screening, Spurling’s test, and cervical range of motion testing assist differentiation.
  • Adhesive capsulitis: Characterised by a global, painful restriction of passive and active glenohumeral range of motion in a capsular pattern, with passive external rotation most severely restricted. A 2023 epidemiological study of over 50,000 older adults in Germany found a one-year prevalence of adhesive capsulitis of 0.4% in people aged 65 and over, with musculoskeletal injury as a major associated risk factor.[25]
  • Acromioclavicular joint pathology: Produces pain specifically localised to the acromioclavicular joint (at the top of the shoulder), reproduced by cross-body horizontal adduction. Direct palpation tenderness over the joint assists identification.
  • Thoracic outlet syndrome (TOS): Compression of the neurovascular structures, including brachial plexus, subclavian artery, or subclavian vein, at the thoracic outlet produces upper limb pain, paraesthesia, and weakness. Forward head posture and hyperkyphosis may contribute to thoracic outlet narrowing.[5] Provocative tests such as the roos test and adson test assist in identification.

[28]

[29]

[30]

[31]

[32]


Physiotherapy Management

Physiotherapy is the cornerstone of management for hyperkyphosis-related shoulder dysfunction. Treatment must address both the thoracic spine and the shoulder concurrently, as the scapular malpositioning driven by hyperkyphosis will perpetuate shoulder symptoms if the thoracic spine is not included in rehabilitation.[6]

Thoracic Spine Interventions

Thoracic Manual Therapy

Thoracic manual therapy produces clinically meaningful improvements in shoulder pain and disability in people with subacromial pain syndrome (SPS).[6] [33]A 2025 PROSPERO-registered systematic review of 10 RCTs involving 444 participants found that thoracic spine manual therapy, delivered in isolation or combined with exercise, significantly reduced pain and disability in people with subacromial pain syndrome, particularly in the short term.[6] These techniques include:

  • High-velocity low-amplitude (HVLA) thrust manipulation of the thoracic spine
  • Non-thrust posterior-anterior mobilisation at thoracic vertebral segments
  • Mulligan Sustained Natural Apophyseal Glides (SNAGs) applied to the thoracic spine
Thoracic Mobilisation

A 2026 RCT where 32 people with SPS and hyperkyphosis demonstrated that thoracic mobilisation combined with a home exercise programme produced significantly greater improvements in acromiohumeral distance, thoracic kyphosis angle, pain intensity and shoulder function, compared to exercise alone over 12 weeks.[10] These findings confirm that restoring thoracic mobility, increases subacromial space and improves shoulder outcomes.

Thoracic Extension Exercise

Thoracic extension exercises directly address the hyperkyphotic posture driving scapular malpositioning. A randomised controlled pilot study demonstrated that combining thoracic joint mobilisation with thoracic extension exercise produced significantly greater improvements in thoracic kyphosis angle, shoulder range of motion and SPADI scores than either intervention alone over four weeks.[34]

Exercises include:

  • Thoracic extension over a foam roller
  • Active thoracic extension in prone lying
  • Postural correction exercises in standing and sitting with active scapular retraction and depression

Scapular Stabilisation Exercises

Scapular stabilisation exercises (SSE) target the lower and middle trapezius, serratus anterior and rhomboids, the muscle groups most consistently inhibited in people with hyperkyphosis-related shoulder dysfunction.[11] A 2022 expert consensus study involving 16 experienced physiotherapists identified the following exercises as most clinically relevant for scapular rehabilitation in people with RCRSP:[12]

  • wall slides
  • prone Y/T/W exercises
  • serratus anterior punchouts
  • side-lying external rotation
  • resistance band rows

A 2025 RCT comparing a scapular-focused exercise protocol against general control therapy in 60 people with RCRSP found that the scapular-focused protocol produced significant short-term improvements in pain and function, confirming the clinical value of targeted scapular rehabilitation. [35]

Physiotherapists should progress exercises systematically:

  1. Isolated scapular muscle activation in supported, gravity-eliminated positions
  2. Scapular control during arm elevation against gravity
  3. Loaded scapular exercises with progressive resistance
  4. Functional and task-specific training for occupational or sporting demands

Rotator Cuff Strengthening

Rotator cuff strengthening restores dynamic glenohumeral stability and complements scapular stabilisation. A 2025 PROSPERO-registered systematic review and meta-analysis of 13 studies found that specific exercise programmes, including scapular stabilisation exercises, shoulder mobilisation and eccentric exercise, moderately alleviated RCRSP symptoms and improved function, with scapular stabilisation exercises specifically improving pain and DASH scores.[36] Recommended exercises include external rotation with a resistance band, side-lying external rotation, prone horizontal abduction and progressive overhead reaching tasks.

A 2025 systematic review and meta-analysis further confirmed that rehabilitation interventions incorporating active exercise or progressive strength training, that combine eccentric exercises with neuromuscular electrical stimulation (NMES) are the most effective in improving strength of shoulder abduction, external rotation and internal rotation in people with RCRSP and should be recommended as a core component of management.[37]

Stretching and Muscle Flexibility Restoration

Stretching of shortened anterior shoulder muscles restores normal muscle length and reduces the anterior pull. A 2023 RCT demonstrated that combined pectoralis minor stretching and lower trapezius strengthening significantly corrected rounded shoulder posture and improved shoulder flexion range of motion in participants with scapular malpositioning.[11]

Clinically relevant stretches include:

  • Doorway pectoral stretch targeting the pectoralis major and minor
  • Thoracic extension over a foam roller to lengthen the anterior thoracic structures
  • Cross-body posterior capsule stretch to address posterior shoulder tightness

Postural Awareness and Education

Postural awareness training supports the development of corrected resting posture in standing and sitting. Evidence supports the use of visual feedback such as a mirror, tactile feedback achieved by taping and hands-on cueing and auditory cues from the physiotherapist to reinforce postural correction.[34]

People should receive education on the relationship between thoracic posture and shoulder symptoms to support long-term self-management. This includes ergonomic advice for workstation setup, guidance on sleeping position and techniques for lifting and reaching that minimise excessive thoracic flexion and shoulder strain.[1]

Summary

Thoracic hyperkyphosis significantly alters shoulder mechanics by disrupting scapular resting position, scapulohumeral rhythm, and the subacromial space, predisposing people to rotator cuff-related shoulder pain, subacromial pain syndrome and adhesive capsulitis.[4] [5]The primary mechanism is a hyperkyphosis-driven scapular malpositioning,[4] combined with predictable muscle imbalances involving shortening of the pectoralis minor and inhibition of the lower trapezius and serratus anterior.[11]

Physiotherapy is the primary treatment approach, combining thoracic manual therapy, thoracic mobilisation, thoracic extension exercise, scapular stabilisation exercises, rotator cuff strengthening, anterior muscle stretching and postural awareness training. Current evidence confirms that addressing the thoracic spine concurrently with the shoulder, rather than treating the shoulder in isolation, produces significantly superior clinical outcomes.[6]

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Koelé MC, Lems WF, Willems HC. The Clinical Relevance of Hyperkyphosis: A Narrative Review. Front Endocrinol (Lausanne). 2020 Jan 24;11:5.
  2. ↑ 2.0 2.1 Gasavi Nezhad Z, A Gard S, Arazpour M. The effects of Hyperkyphosis on Balance and Fall Risk in older adults: A Systematic Review. Gait Posture. 2025 May;118:154-167.
  3. ↑ Koelé MC, van der Velde N, van Campen JPCM, van Haelst SAE, Willems HC. The association between hyperkyphosis and physical function in geriatric outpatients with frailty. Arch Osteoporos. 2026 Jan 8;21(1):21.
  4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 Otoshi K, Takegami M, Sekiguchi M, Onishi Y, Yamazaki S, Otani K, Shishido H, Kikuchi S, Konno S. Association between kyphosis and subacromial impingement syndrome: LOHAS study. J Shoulder Elbow Surg. 2014 Dec;23(12):e300-e307. Epub 2014 Aug 5.
  5. ↑ 5.0 5.1 5.2 5.3 5.4 5.5 5.6 Manoso-Hernando D, Bailón-Cerezo J, Angulo-Díaz-Parreño S, Reina-Varona Á, Elizagaray-García I, Gil-Martínez A. Shoulder mobility and strength impairments in patients with rotator cuff related shoulder pain: A systematic review and meta analysis. PeerJ. 2024 Jun 26;12:e17604.
  6. ↑ 6.0 6.1 6.2 6.3 6.4 Robles-Pérez R, Vallejo-Martínez R, Carrasco-Uribarren A, Jiménez-Del-Barrio S, Hernández-Lázaro H, Ceballos-Laita L. Thoracic Manual Therapy With or Without Exercise Improves Pain and Disability in Subacromial Pain Syndrome: A Systematic Review of Randomized Trials. Healthcare (Basel). 2025 Sep 29;13(19):2479.
  7. ↑ Paine R, Voight ML. The role of the scapula. Int J Sports Phys Ther. 2013 Oct;8(5):617-29.
  8. ↑ 8.0 8.1 8.2 8.3 8.4 8.5 Fernández-Matías R, Ballesteros-Frutos J, Gallardo-Zamora P, Requejo-Salinas N, Caballero-Pozo I, Ludewig P, Lluch-Girbés E. Scapular kinematics variability in individuals with and without rotator cuff-related shoulder pain: A systematic review with multilevel meta-regression. Braz J Phys Ther. 2025 Nov-Dec;29(6):101261.
  9. ↑ 9.0 9.1 Gu Q, Pan L, Yu L, Jiang Q. Effect of scapular posterior tilting exercise on scapular muscle activities in men and women with a rounded shoulder posture. J Orthop Surg Res. 2024 Jun 28;19(1):383.
  10. ↑ 10.0 10.1 10.2 10.3 10.4 Calik M, Kara D, Terzi MM, Bezirgan U, Misirli S, Kaya Utlu D, Duzgun I. Effect of thoracic mobilization on acromio-humeral distance, thoracic kyphosis angle, pain and shoulder function in patients with subacromial impingement syndrome: A randomized controlled trial. Eur Spine J. 2026 Feb;35(2):354-367.
  11. ↑ 11.0 11.1 11.2 11.3 11.4 11.5 11.6 Hasan S, Iqbal A, Alghadir AH, Alonazi A, Alyahya D. The Combined Effect of the Trapezius Muscle Strengthening and Pectoralis Minor Muscle Stretching on Correcting the Rounded Shoulder Posture and Shoulder Flexion Range of Motion among Young Saudi Females: A Randomized Comparative Study. Healthcare (Basel). 2023 Feb 8;11(4):500.
  12. ↑ 12.0 12.1 12.2 12.3 Dubé MO, Arel J, Paquette P, Roy JS, Desmeules F, Gagnon DH. Co-creation of an exercise inventory to improve scapular stabilization and control among individuals with rotator cuff-related shoulder pain: a survey-based study amongst physiotherapists. Arch Physiother. 2022 Apr 12;12(1):11.
  13. ↑ 13.0 13.1 13.2 Alfaya FF, Reddy RS, Alkhamis BA, Kandakurti PK, Mukherjee D. Shoulder Proprioception and Its Correlation with Pain Intensity and Functional Disability in Individuals with Subacromial Impingement Syndrome-A Cross-Sectional Study. Diagnostics (Basel). 2023 Jun 17;13(12):2099.
  14. ↑ Nepomuceno AP, Cury AC, Pinheiro LS, Sabino GS, Souza TR, Fonseca ST, Ocarino JM, Resende RA. Validity, reliability, and clinical usefulness of instruments for measuring thoracic kyphosis: a systematic review and meta-analysis. Brazilian Journal of Physical Therapy. 2025 Sep 1;29(5):101246.
  15. ↑ Ortho Eval Pal with Paul Marquis PT Hawkins Kennedy Test for Subacromial Pain Available from https://www.youtube.com/watch?v=8kSXeXFGuME (Last accessed 1.6.2026)
  16. ↑ Ortho Eval Pal with Paul Marquis PT Neer´s Test for Subacromial Pain Available from https://www.youtube.com/watch?v=Sa9PgmHajrI (Last accessed 1.6.2026)
  17. ↑ Ortho Eval Pal with Paul Marquis PT Empty Can Test / Jobe TEst (Supraspinatus Special Test) Available from https://www.youtube.com/watch?v=Vsq2iAPnPEQ (Last accessed 1.6.2026)
  18. ↑ Physical Therapy Nation External Rotation Lag Sign Available from https://www.youtube.com/watch?v=AzDQ9s3qipg (Last accessed 1.6.2026)
  19. ↑ Care Arthritis Occiput to Wall Distance (English Original) Available from https://www.youtube.com/watch?v=chTkThvHuhs (Last accessed 1.6.2026)
  20. ↑ 20.0 20.1 Venturin D, Giannotta G, Pellicciari L, Rossi A, Pennella D, Goffredo M, Poser A. Reliability and validity of the Shoulder Pain and Disability Index in a sample of patients with frozen shoulder. BMC Musculoskelet Disord. 2023 Mar 22;24(1):212.
  21. ↑ Roach KE, Budiman‐Mak E, Songsiridej N, Lertratanakul Y. Development of a Shoulder Pain and Disability Index. Arthritis Care Res 1991; 4: 143–9.
  22. ↑ Beaton DE, Katz JN, Fossel AH, Wright JG, Tarasuk V, Bombardier C. Measuring the whole or the parts?: validity, reliability, and responsiveness of the Disabilities of the Arm, Shoulder and Hand outcome measure in different regions of the upper extremity. Journal of Hand Therapy. 2001 Apr 1;14(2):128-42.
  23. ↑ Williamson A. Pain: a review of three commonly used pain rating scales. Issues in Clinical Nursing 2005; 14: 798–804
  24. ↑ Kang KC, Lee HS, Lee JH. Cervical Radiculopathy Focus on Characteristics and Differential Diagnosis. Asian Spine J. 2020 Dec;14(6):921-930.
  25. ↑ Jacob L, Gyasi RM, Koyanagi A, Haro JM, Smith L, Kostev K. Prevalence of and Risk Factors for Adhesive Capsulitis of the Shoulder in Older Adults from Germany. J Clin Med. 2023 Jan 14;12(2):669.
  26. ↑ Dalton SE, Snyder SJ. Glenohumeral instability. Baillieres Clin Rheumatol. 1989 Dec;3(3):511-34.
  27. ↑ Teixeira DC, Alves L, Gutierres M. The role of scapular dyskinesis on rotator cuff tears: a narrative review of the current knowledge. EFORT Open Rev. 2021 Oct 19;6(10):932-940.
  28. ↑ MSK Medicine Spurling´s Test Available from https://www.youtube.com/watch?v=h8GxF73P6GQ (Last accessed 1.6.206)
  29. ↑ MSK Medicine Roos Test (Thoracic Outlet Syndrome) Available from https://www.youtube.com/watch?v=MQgNJSERivE (Last accessed 1.6.2026)
  30. ↑ MSK Medicine Adsons´s Test Available from https://www.youtube.com/watch?v=6aaCspvqQHQ (Last accessed 1.6.2026)
  31. ↑ MSK Medicine Apprehension Test (Shoulder) Available from https://www.youtube.com/watch?v=K2XpphO6Wls (Last accessed 1.6.2026)
  32. ↑ MSK Medicine Fowler´s Sign (Relocation Test) Available from https://www.youtube.com/watch?v=HnjKGuaxOeU (Last accessed 1.6.2026)
  33. ↑ Hunter DJ, Rivett DA, McKiernan S, Luton R, Snodgrass SJ. Thoracic Manual Therapy Improves Pain and Disability in Individuals With Shoulder Impingement Syndrome Compared With Placebo: A Randomized Controlled Trial With 1-Year Follow-up. Arch Phys Med Rehabil. 2022 Aug;103(8):1533-1543.
  34. ↑ 34.0 34.1 Park SJ, Kim SH, Kim SH. Effects of Thoracic Mobilization and Extension Exercise on Thoracic Alignment and Shoulder Function in Patients with Subacromial Impingement Syndrome: A Randomized Controlled Pilot Study. Healthcare (Basel). 2020 Sep 2;8(3):316.
  35. ↑ Dos Santos C, Bastos de Almeida I, Jones MA, Matias R. Effects of a Scapular-Focused Exercise Protocol for Patients with Rotator Cuff-Related Pain Syndrome—A Randomized Clinical Trial. Journal of Functional Morphology and Kinesiology. 2025 Dec 9;10(4):475.
  36. ↑ Wu D, Wen Z, Ke H, Zhang J, Zhong S, Teng J, Xu L, Li J, Shao Y, Zeng C. Specific modes of exercise to improve rotator cuff-related shoulder pain: systematic review and meta-analysis. Front Bioeng Biotechnol. 2025 Apr 8;13:1560597.
  37. ↑ Zhang B, Raguzzi IA, Dupuis F, Gianola S, Morgan-Daniel J, Roy JS, Pozzi F. Addressing Shoulder Weakness in Individuals With Rotator Cuff-Related Shoulder Pain: A Systematic Review With Meta-analysis. J Orthop Sports Phys Ther. 2026 Feb;56(2):67-84.
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