ARTICLE IN PRESS
Manual Therapy 12 (2007) 3 11
www.elsevier.com/locate/math
Review
An evidence-based review on the validity of the Kaltenborn rule as
applied to the glenohumeral joint
Corlia Brandta, , Gisela Soleb, Maria W. Krausea, Mariette Nelc
a
Department of Physiotherapy, Faculty of Health Sciences, University of the Free State, South Africa
b
Musculoskeletal and Sports Physiotherapy, School of Physiotherapy, University of Otago, New Zealand
c
Department of Biostatistics, Faculty of Health Sciences, University of the Free State, South Africa
Received 25 January 2005; received in revised form 26 January 2006; accepted 15 February 2006
Abstract
Kaltenborn s convex concave rule is a familiar concept in joint treatment techniques and arthrokinematics. Recent investigations
on the glenohumeral joint appear to question this rule and thus accepted practice guidelines. An evidence-based systematic review
was conducted to summarize and interpret the evidence on the direction of the accessory gliding movement of the head of the
humerus (HOH) on the glenoid during physiological shoulder movement. Five hundred and eighty-one citations were screened.
Data from 30 studies were summarized in five evidence tables with good inter-extracter agreement. The quality of the clinical trials
rated a mean score of 51.27% according to the Physiotherapy Evidence Database scale (inter-rater agreement: kź 0:6111).
Heterogeneity among studies precluded a quantitative meta-analysis. Weighting of the evidence according to Elwood s classification
and the Agency for Health Care Policy and Research classification guidelines indicated that evidence was weak and limited. Poor
methodological quality, weak evidence, heterogeneity and inconsistent findings among the reviewed studies regarding the direction
of translation of the HOH on the glenoid, precluded the drawing of any firm conclusions from this review. Evidence, however,
indicated that not only the passive, but also the active and control subsystems of the shoulder may need to be considered when
determining the direction of the translational gliding of the HOH. The indirect method, using Kaltenborn s convex concave rule as
applied to the glenohumeral joint, may therefore need to be reconsidered.
r 2006 Elsevier Ltd. All rights reserved.
Keywords: Glenohumeral; Translational glide; Evidence-based; Kaltenborn
Contents
1. Introduction/background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
2. Methodology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
2.1. The search strategy and data selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
2.2. Quality assessment of the clinical trials. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
2.3. Meta-analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
2.4. Weighting of the evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
3.1. Study characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
3.2. Methodological quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
3.3. Meta-analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
3.4. Level of the evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Corresponding author. P.O. Box 339 (G30), Bloemfontein 9300, South Africa. Tel: [phone]; fax: [phone].
E-mail address: [e-mail] (C. Brandt).
1356-689X/$ - see front matter r 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.math.2006.02.011
ARTICLE IN PRESS
4 C. Brandt et al. / Manual Therapy 12 (2007) 3 11
4. Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
4.1. Methodological quality of the clinical trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
4.2. The evidence on the arthrokinematics of the glenohumeral joint. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
4.3. Relating the findings to Kaltenborn s rule and theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
4.4. Implications and recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
4.5. Limitations of this review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1. Introduction/background Kaltenborn and Evjenth (1989) thus based the clinical
reasoning of appropriate direction of translational glide
Dysfunction of the shoulder girdle is one of the most mainly on the anatomy of the osseous articulating
common musculoskeletal conditions to be treated in surfaces. More recently it has been suggested that other
primary care. Thirty-four per cent of the general factors, such as the concept of functional stability
population may suffer from shoulder pain at least once (Panjabi, 1992), may also need to be considered in the
in their lifetime (Green et al., 2002). In addition to the assessment of the arthrokinematics of the glenohumeral
high incidence rate, shoulder dysfunction is often joint (Hess, 2000). The question thus arose whether the
persistent and recurrent (Winters et al., 1999). convex concave rule is valid in the clinical reasoning of the
Physiotherapy for shoulder dysfunction may include most appropriate direction of translational glide applied in
manual therapy joint techniques to treat pain or stiffness. the assessment and treatment of shoulder dysfunction.
Various approaches to treatment have been proposed, The aim of this study was to investigate the evidence
such as the Maitland approach (Maitland, 1998), move- on the arthrokinematics of the glenohumeral joint
ment with mobilization (Mulligan, 1999), and the supporting or negating the validity of the MacConaill
application of passive mobilization techniques following and Kaltenborn rule and theory.
the convex concave rule (Kaltenborn and Evjenth, 1989).
The latter approach is based on direct and indirect
assessment of translational glides. Using the direct 2. Methodology
method, the passive translational gliding movements
are performed by the therapist to the patient s painful 2.1. The search strategy and data selection
and/or stiff joint to determine which direction may be
limited (Kaltenborn and Evjenth, 1989). Joint mobiliza- An academic, computerized search was conducted.
tions would then be performed as a treatment method in CINAHL, MEDLINE, The Cochrane Controlled trials
the decreased direction to restore normal movement. register of randomized controlled trials, Kovsiedex,
The indirect method of determining the direction of South African Studies and Sport Discussion were
translational glide was termed the   Kaltenborn con- searched from 1966 to October 2003. The search was
vex concave rule  (Kaltenborn and Evjenth, 1989). This limited to English and human studies. Keywords such as
rule was first described by MacConaill (1953). Following shoulder, glenohumeral, kinematics, arthrokinematics,
this method, the therapist examines active and passive mechanics, translation(al), roll(-ing) and/or glide(-ing),
physiological movements such as flexion, extension, accessory movement, and Kaltenborn were optimally
abduction and lateral rotation (Kaltenborn and combined. The search was continued over a period of
Evjenth, 1989). The direction of the glide would then ten months (Hoepfl, 2002).
be determined by considering the geometry of the The titles and the abstracts of the retrieved citations
moving articular surfaces. In the glenohumeral joint, were screened for relevance by the primary investigator.
the glenoid fossa (concave surface) was considered to be The reference lists of the relevant articles were checked
stable (fixed) while the humeral head (convex surface) by one reviewer to identify additional publications. Five
would be moved (mobilized) during a physiological clinical experts in the field of shoulder orthopaedics were
shoulder movement. According to the convex concave also contacted in order to retrieve data (Oxman et al.,
rule, the convex surface (humeral head) would glide 1994; Mays and Pope, 1999; Green et al., 2002; Tugwell
in the opposite direction to the bone movement. et al., 2003).
Thus, during abduction of the arm, the humeral head The second screening consisted of the blinded assess-
would glide caudally. Kaltenborn and Evjenth (1989) ment of the full papers Method and Results sections by
proposed that for restricted shoulder extension and two independent reviewers. The reports were numbered at
lateral rotation, the humeral head should be glided random and the authors names and affiliations, the name
ventrally (anteriorly), and for restricted flexion and of the journal, the date of publication, and the acknowl-
medial rotation, the humeral head should be glided edgements were erased to ensure blinded assessment. All
dorsally (posteriorly). types of study designs were included in the systematic
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C. Brandt et al. / Manual Therapy 12 (2007) 3 11 5
review to increase its clinical value (Mays and Pope, 1999; calculated. A study was considered as high quality if it
Elwood, 2002; Hoepfl, 2002; Fritz and Cleland, 2003). In satisfied at least 50% of the criteria (X5.5 points)
vivo and in vitro studies were assessed. The investigated (Maher et al., 2003; Scholten-Peeters et al., 2003). The k
population had to be human (male and/or female), a mean statistic and the 95% confidence level provided for
age of 15 years or older, with or without shoulder measurement of interobserver agreement (Maher et al.,
pathology. The study had to investigate a variable factor 2003; Scholten-Peeters et al., 2003).
regarding glenohumeral joint translation and had to
measure the direction of translation of the humeral head 2.3. Meta-analysis
on the glenoid fossa during normal or simulated, active or
passive physiological shoulder movement. The reviewers Clinical trials were considered for meta-analysis regard-
decided upon inclusion by means of consensus (Oxman et less of their quality score in order to reduce bias (Guyatt et
al., 1994; Jadad et al., 1996). al., 1995; Woolf, 2000). The following study characteristics
Data were extracted from the included reports and were compared by two independent reviewers in order to
summarized on a standardized data collection form by identify the possibility of statistical pooling of results: (i)
two independent, masked reviewers. The form provided the study populations, (ii) the interventions, (iii) the sample
for the gathering of information on the study design, sizes, (iv) the availability and format of the results, (v) the
subgroups, exposure or intervention, study population, statistical methodology used for analysis, and (vi) the
research methodology, data analysis, main results, hypotheses tested (Dickersin and Berline, 1997).
hypotheses, and any other relevant data (Oxman et al.,
1994; Elwood, 2002; Scholten-Peeters et al., 2003; 2.4. Weighting of the evidence
Tugwell et al., 2003). The data were recorded (by means
of consensus) as stated in the report. Where data were The strength of the scientific evidence was rated by two
unclear and biased recording a possibility, it was clearly analysts according to two classification systems (Moher
indicated (Scholten-Peeters et al., 2003). et al., 1996; Elwood, 2002; Mays and Pope, 2002) namely,
(i) a hierarchy of evidence (Table 1) relevant to human
2.2. Quality assessment of the clinical trials health studies (Elwood, 2002) and (ii) the modified
classification of the Agency for Health Care Policy and
The quality of the clinical trials were assessed by means Research (AHCPR) guidelines (Table 2) on acute low
of the 11-item Physiotherapy Evidence Database (PEDro) back problems in adults (Ejnisman et al., 2002).
scale which was developed by the Centre for evidence-
based Physiotherapy, University of Sydney. The PEDro 3. Results
scale measures the internal validity and the sufficiency of
the statistical information provided by a clinical trial. The 3.1. Study characteristics
scale assesses criteria such as random allocation, conceal-
ment of allocation, comparibility of groups at baseline, Fig. 1 depicts the results yielded by the search and
blinding of patients, therapists and assessors, analysis by selection process. Eighteen clinical trials, seven compara-
intention to treat, adequacy of follow-up, between group tive, and five descriptive studies were included in the
statistical comparisons, report of point estimates, and review. Summary of the data indicated major methodolo-
measures of variability. Though the PEDro scale does not gical heterogeneity. Researchers used various protocols
usually assess the external validity of a trial, this item from and measuring instruments such as magnetic tracking
the Delphi list (upon which the PEDro scale is based), was devices or position sensors (nź11), three-dimensional
included in the assessment. Verhagen et al. (1998) magnetic resonance imaging (nź4), computertomogra-
reported that external validity should form part of any phy (nź3), ultrasonic devices (nź2), potentiometers
concept of quality (Verhagen et al., 1998; Woolf, 2000; (nź3), radiographs (nź6), and arthroscopy (nź1) for
  PEDro: frequently asked questions  , 2003). investigation. Eleven studies were conducted in vivo and
Two masked reviewers independently scored the quality 19 in vitro. Movements were either done passively (nź15)
of the studies (Jadad et al., 1996; Moher et al., 1996; or actively (nź14); simulated, static or continuous, while
Dickersin & Berline, 1997). Criteria were rated as yes when the plane of motion also varied. Data were gathered on
they were clearly satisfied on reading of the report, as no eight different physiological movements performed
when an unbiased decision could be made that the criteria through a variety of ranges of motion. The movements
were not satisfied, and as don t know when the information of active flexion, active extension, and passive horizontal
was insufficient or unclear and a biased decision possible. extension were not included in any investigation.
Points were allocated for all the clearly satisfied items The literature indicated six main factors to explain
(Verhagen et al., 1998;   PEDro: the PEDro scale  , 2003). the translational behaviour of the humeral head namely,
The mean quality score, the total frequency results, as the influence of (i) the capsulo-ligamentous structu-
well as the frequency results on each item were res (nź17), (ii) neuromuscular control (nź17),
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6 C. Brandt et al. / Manual Therapy 12 (2007) 3 11
Table 1
Elwood s hierarchy of evidence
Level Definition of type of evidence
1 Randomized intervention trials, properly performed on an adequate number of subjects, in a human situation.
1m Results from a meta-analysis of trials.
1s One or more individual trials.
2 Observational studies, namely cohort and case control designs, of appropriately selected groups of subjects.
2m Results from a meta-analysis of such studies.
2s One or more individual studies.
3 Comparative studies that compares groups of subjects representative of different populations or subject groups. For example:
correlation studies of populations in which data on each individual are not assessed separately and informal comparisons between
patients.
4 Case series, descriptive studies, professional experience. The evidence is largely anecdotal, unsystematically recollected (for example
  clinical judgement  and   experience  ), conclusions based on traditional practice, information derived from other species, in vitro
testing, basic physiological principles and indirect assessments.
Table 2
The modified classification of the AHCPR guidelines on acute low back problems in adults
Level Definition of type of evidence
A Strong research-based evidence provided by generally consistent findings in multiple (more than one) high-quality randomized
clinical trial (RCT).
B Moderate research-based evidence provided by generally consistent findings in one high-quality RCT and one or more low-quality
RCT, or generally consistent findings in multiple low quality RCTs.
C Limited research-based evidence provided by one RCT (either high or low quality) or inconsistent or contradictory evidence
findings in multiple RCTs.
D No research-based evidence: no RCTs.
(iii) articular geometry/congruency/conformity (nź8), According to Elwood s classification (Table 1), one
(iv) negative intra-articular pressure (nź4), (v) rigidi- study fulfilled the criteria for level 2 s evidence, five
fication of musculature (nź1), and (vi) gravity (nź1). for level 3 and 19 studies for level 4 evidence. The
Agreement between the reviewers were 100% for the level 2 s evidence found (i) translation to be in the
data extracted on the sample and methodological opposite direction during active physiological move-
characteristics. Disagreement occurred only on the ment in pathological joints and (ii) the humeral
study design in two of the studies which was resolved head to remain centered during active physiologi-
by means of consensus. cal movement in normal joints (Paletta et al., 1997).
For all other stratified movement planes, only levels
3.2. Methodological quality
3 and 4 evidence were found. Table 4 summar-
izes the amount and level of evidence found on the
The mean PEDro score of the clinical trials equalled
direction of the translational movement of the humeral
51.27%. Table 3 summarizes the individual results. The
head.
inter-rater agreement for quality assessment was poor
According to the AHCPR rating system (Table 2),
(kź 0:611). This was confirmed by the 95% con-
level C evidence is contradictory on the direction of
fidence level of [ 0.8661; 0.3562].
translation during active and passive lateral rotation in
901 of elevation in normal and reconstructed joints
3.3. Meta-analysis
(Karduna et al., 1997; Williams et al., 2001). Only
Heterogeneity among studies, insufficient reported inconsistent, level D evidence could be found on the
data, and poor study quality precluded statistical translation occurring during physiological movements
pooling of results. in other planes.
Inclusion of only higher quality clinical trials (quality
score X54.5%) in the weighting of the evidence indu-
3.4. Level of the evidence
ced the following changes: according to Elwood s
Twenty-five of the reviewed studies were analysed classification, only level 4 evidence was now available,
qualitatively. Five studies were excluded due insufficient while the level of evidence according to the AHCPR
information provided for classification purposes. rating system, remained unchanged.
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C. Brandt et al. / Manual Therapy 12 (2007) 3 11 7
COMPUTER-BASED SEARCH
of databases: 555 citations
First screening: retrieved and
6 articles not available
read 56 articles
internationally
Articles included for quality
assessment = 11
21 articles were selected,
summarized, and data extracted
10 articles were excluded from
quality assessment because of
study design
REFERENCE CHECKING: 26
articles identified, 21 retrieved
and screened
5 articles not available
internationally
Articles included for quality
assessment = 7
9 articles were selected,
summarized, and data extracted
2 articles were excluded from
quality assessment because of
study design
RESPONSE FROM EXPERTS:
00 articles
Total relevant articles
reviewed = 30
Fig. 1.
4. Discussion results (to be discussed in the next section). According to
the PEDro scale, methodological shortcomings of the
4.1. Methodological quality of the clinical trials clinical trials concerned mostly the insufficient reporting
of random allocation, insufficient reporting of conceal-
Analysis of the methodology used by some of the ment of allocation, and insufficient or unclear descrip-
included studies lead to serious concerns regarding the tion of blinding of therapists and assessors. This may
biomechanical and neurophysiological validity of their indicate that many of the clinical trials were, in fact, not
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8 C. Brandt et al. / Manual Therapy 12 (2007) 3 11
randomized, which may raise some concern regarding A quality score of 50 60% have been suggested as a
the appropriateness of the PEDro scale for assessing cut-off to distinguish between good and poor quality
these trials (Verhagen et al., 1998). It should be noted, studies (Maher et al., 2003; Scholten-Peeters et al.,
though, that poor reporting does not necessarily imply 2003). The mean quality score of 51.27% together with
that the criteria were not satisfied during the execution the poor inter-rater agreement (kź 0:611) necessitated
of the trial (Elwood, 2002). careful consideration regarding the methodological
quality of the included clinical trials (Oxman et al.,
1994; Elwood, 2002; Scholten-Peeters et al., 2003).
Table 3
The best approach when comparing the agreement
Summary of the quality scores of clinical trials
between two raters is to calculate the k statistic. Similar
Study Mean quality scores
to other methods, such as McNemar s test which was
(out of 11)
also calculated (0.3103), small frequency tables (in this
study nź30) present difficulties associated with the use
Level 2s evidence
Paletta et al. 1997 5
and interpretation of kappa (Altman, 1996; Elwood,
Level 4 evidence
2002). The problem most cited is that the value of k
Karduna et al. (1997) 7
depends upon the proportion of subjects in each
Harryman et al. (1992) 6
category. Landis and Koch (1977), as well as Elwood
Harryman et al. (1990) 6
(2002), have characterized ranges of values for kappa
McMahon et al. (1995) 4.5
Gohlke et al. (1994) 6
with respect to the degree of agreement they suggest.
Vaesel et al. (1997) 5
Values greater than 0.75 may be taken to represent
Novotny et al. (1998) 4.5
excellent agreement beyond chance, values below 0.40
Williams et al. (2001) 6.5
may be taken to represent poor agreement beyond
Apreleva et al. (1998) 6
chance, and values between 0.40 and 0.75 may be taken
Wuelker et al. (1994) 6
Loehr et al. (1994) 5
to represent fair to good agreement beyond chance.
Karduna et al. (1996) 6
Thompson et al. (1996) 5
4.2. The evidence on the arthrokinematics of the
Helmig et al. (1993) 6
glenohumeral joint
Wuelker et al. (1998) 6
Debski et al. (1995) 5
The best evidence (level 2 s), as well as many of the
Total mean score 5.64
selected studies (nź17), supported the hypotheses of
Table 4
Levels of evidence
Physiological movement Direction of translation of humeral head
Same Opposite Centered Non-uniform
Active: normal joints nź8 nź2 nź5 
Level: 3 (nź1) Level: 3 (nź1) Level: 2s (nź1)
4 (nź7) 4 (nź1) 3 (nź1)
4 (nź3)
Level: C Level: C Level: D Level: D
Active: pathological joints nź7 nź3 nź2 
Level: 3 (nź1) Level: 2s (nź1) Level: 4 (nź2)
4 (nź6) 3 (nź1)
4 (nź1)
Level: C Level: C Level: D Level: D
Passive: normal joints nź6 nź2 nź1 nź4
Level: 3 (nź1) Level: 3 (nź1) Level: 4 (nź1) Level: 3 (nź1)
4 (nź5) 4 (nź1) 4 (nź3)
Level: C Level: C Level: D Level: D
Passive: pathological joints nź7 nź3 nź1 nź2
Level: 3 (nź1) Level: 4 (nź3) Level: 4 (nź1) Level: 3 (nź1)
4 (nź6) 4 (nź1)
Level: C Level: C Level: D Level: D
Levels of evidence are indicated according to Elwood s classification system (normal print) and according to the AHCPR s guidelines (in italics).
 , No evidence; nźamount of studies.
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C. Brandt et al. / Manual Therapy 12 (2007) 3 11 9
capsulo-ligamentous structures and neuromuscular con- 450%) were contradicting regarding the translational
trol influencing the translation of the head of the direction during active and passive lateral rotation in 901
humerus (HOH). The capsulo-ligamentous structures of elevation in normal and reconstructed joints (Karduna
may be responsible for an obligatory translation of the et al., 1997; Williams et al., 2001).
humeral head at the end range of motion when the Considering Table 4, interpretations with regards to the
capsule and/or ligaments are tensioned. This was convex concave rule need to be made with caution due to
especially observed during passive motion in the absence the following limitations: (i) the table is not representative
of rotator cuff activity (Howell et al., 1988; Harryman of all physiological movements since certain motion planes
et al., 1990, 1992; Gohlke et al., 1994; Debski et al., were not investigated by any of the studies; (ii) findings
1995; Karduna et al., 1996, 1997; Paletta et al., 1997; regarding the direction of translation were inconsistent for
Novotny et al., 1998; Rhoad et al., 1998; Baeyens et al., different physiological motion planes, and (iii) hetero-
2000; Williams et al., 2001). During active movement the geneous shoulder pathologies were grouped together,
stabilizing effect of the rotator cuff on the humeral head although these may affect translation in different manners
causes a centring motion (Poppen and Walker, 1976; (Burkhart, 1994; Meister, 2000).
Howell et al., 1988; Gohlke et al., 1994; Wuelker et al.,
1994, 1998; Debski et al., 1995; Karduna et al., 1996; 4.3. Relating the findings to Kaltenborn s rule and theory
Thompson et al., 1996; Karduna et al., 1997; Paletta
et al., 1997; Apreleva et al., 1998; Rhoad et al., 1998; Kaltenborn and MacConaill based their hypotheses
Graichen et al., 2000; Williams et al., 2001; Von of normal and abnormal intra-articular dynamics on the
Eisenhart-Rothe et al., 2002). Any loss of or defect in geometry of the articulating surfaces and location of the
the stabilizing mechanism of the shoulder joint may movement axis alone (MacConaill, 1953; Kaltenborn
increase or disrupt normal translational patterns, and Evjenth, 1989). The evidence indicates (i) different
depending on the involved structure and its role in the arthrokinematic behaviour for normal and dysfunc-
gliding of the humeral head (Poppen and Walker, 1976, tional joints and (ii) that not only the passive subsystem,
1978; McGlynn and Caspari, 1984; Howell et al., 1988; but also the active and control subsystems may
Ozaki, 1989; Harryman et al., 1990; Helmig et al., 1993; determine intra-articular gliding motion.
Loehr et al., 1994; Debski et al., 1995; McMahon et al., It appears that Kaltenborn s rule for the treatment of
1995; Deutsch et al., 1996; Thompson et al., 1996; restricted joint motion may be valid if the intention of
Karduna et al., 1997; Paletta et al., 1997; Apreleva et al., the treatment is to stretch a tight capsulo-ligamentous
1998; Novotny et al., 1998; Wuelker et al., 1998; structure causing limitation of the physiological joint
Baeyens et al., 2000, 2001; Graichen et al., 2000; Von motion. By gliding the humeral head in the opposite
Eisenhart-Rothe et al., 2002). Pain, muscle spasm, and direction of the restricted physiological bone movement,
loss of proprioception associated with shoulder dysfunc- the restricting capsulo-ligamentous structure may be
tion may lead to neurophysiological responses. Imbal- stretched. According to the evidence, however, this
ance/incoordination of the shoulder musculature may motion performed by the therapist may not necessarily
influence the translation of the humeral head (Poppen mimic the true gliding taking place due to the tight
and Walker, 1976; Wuelker et al., 1994, 1998; Bertoft, structure.
1999; Graichen et al., 2000; Von Eisenhart-Rothe et al.,
2002). 4.4. Implications and recommendations
In correllation with the original theory of MacConaill
and Kaltenborn, some studies did report that geome- Clinically authors postulate that the validity of the
trical factors, such as the size of the humeral head, may Kaltenborn rule might not be accepted dogmatically.
determine translation. Increased head size seems to The arthrokinematics of each patient might need to be
distension the capsule and thus reduce translation considered in the context of existing neuro-musculoske-
(Vaesel et al., 1997; Rhoad et al., 1998). letal and biopsychosocial dysfunction which requires the
To relate the findings of this review on the translational process of clinical reasoning. Scientifically such a
direction of the humeral head to the Kaltenborn rule, the recommendation still lacks evidence.
best evidence will be considered (Elwood, 2002). The level Methodologically sound, randomized, clinically con-
2 s evidence (quality score o50%) found translation to be trolled, in vivo, and homogeneous primary studies are
in the opposite direction during active horizontal needed on this subject. As such studies emerge, this
extension with lateral rotation and in the same direction review should be updated and reproduced. To ensure a
during active abduction in anterior unstable joints and meta-analysis in future reviews, the following criteria
joints with rotator cuff tears. The humeral head remained need to be considered: (i) movement should be classified
centred during active abduction in normal shoulder joints as active or passive, (ii) the plane and the range of
(Paletta et al., 1997). According to the AHCPR motion investigated should be similar, (iii) homogeneous
classification, level C evidence (nź2, quality scores pathologies should be grouped, and (iv) measuring
ARTICLE IN PRESS
10 C. Brandt et al. / Manual Therapy 12 (2007) 3 11
instruments, exposures or interventions, as well as the of the shoulder at the end of the late preparatory phase of
throwing. Clinical Biomechanics 2001;16:752 7.
hypotheses tested, should be similar.
Bertoft ES. Painful shoulder disorders from a physiotherapeutic view:
a review of literature. Physical and Rehabilitation Medicine
4.5. Limitations of this review
1999;11:229 77.
Burkhart SS. Reconciling the paradox of rotator cuff repair versus
debridement: a unified biomechanical rationale for the treatment of
Bias needs to be considered. Only one reviewer was
rotator cuff tears. Arthroscopy 1994;10:4 19.
involved in the initial screening of the 555 citations. A
Debski RE, McMahon PJ, Thompson WO, Woo SLY, Warner JJP,
few articles could not be retrieved internationally and
Fu FH. A new dynamic testing apparatus to study glenohumeral
attempts to retrieve unpublished literature yielded no
joint motion. Journal of Biomechanics 1995;28(7):869 74.
results.
Deutsch A, Altchek DW, Schwartz E, Otis JC, Warren RF. Radiologic
Working with such considerable amounts of evidence measurement of superior displacement of the humeral head in the
impingement syndrome. Journal of Shoulder and Elbow Surgery
could not exclude the possibility of including multiple
1996;5(3):186 493.
publications from the same large trial. Careful inspec-
Dickersin K, Berline T. Combining the results of several studies. In:
tion, though, did not reveal any such errors. Informa-
Lang TA, Secic M, editors. How to report statistics in medicine.
tion from papers concerning the same variables or
American College of Physicians; 1997. p. 171 84 [Chapter 11].
cohorts, may influence the quality rating of similar
Ejnisman B, Carrera EF, Fallopa F, Peccin MS, Cohen M.
Interventions for tears of the rotator cuff in adults (Protocol for
papers later on. Earlier papers can provide the reviewers
a Cochrane Review). In: The Cochrane Library, issue 4. Oxford:
with additional information on validity.
Update Software; 2002.
This review lacks statistical strength due to the
Elwood JM. Critical appraisal of epidemiological studies and clinical
preclusion of a meta-analysis and the poor kappa value
trials, 2nd edn. Oxford: Oxford University Press; 2002. p. 105 115,
calculated for inter-rater agreement. The findings should
198 244. [Chapters 5,8 9].
be interpreted with caution due to the limitations of a Fritz JM, Cleland J. Effectiveness versus efficacy: more than a debate
over language. Journal of Orthopaedic and Sports Physical
qualitative/categorical analysis.
Therapy 2003;33(4):163 5.
Gohlke FE, Barthel T, Daum P. Influence of T-shift capsulography on
rotation and translation of the glenohumeral joint: an experi-
5. Conclusion
mental study. Journal of Shoulder and Elbow Surgery 1994;3:
361 70.
Inconsistent evidence, poor methodological quality
Graichen H, Stammberger T, Bone` l H, Englmeier K- H, Reiser M,
and heterogeneity among the reviewed studies precluded
Eckstein F. Glenohumeral translation during active and passive
elevation of the shoulder a 3D open-MRI study. Journal of
the drawing of any firm conclusions regarding the
Biomechanics 2000;33:609 13.
direction of translation of the humeral head on the
Green S, Buchbinder R, Glazier R, Forbes A. Interventions for
glenoid. The indirect method using Kaltenborn s con-
shoulder pain (Cochrane review). In: The Cochrane library, issue 2.
vex concave rule, as applied to the glenohumeral joint,
Oxford: Update Software; 2002.
need to be investigated appropriately by primary studies
Guyatt GH, Sackett DL, Sinclair JC, Hayward R, Cook DJ, Cook RJ.
to determine its validity. It can only be postulated that User s guide to the medical literature: IX. A method for grading
health care recommendations. Journal of the American Medical
not only the passive subsystem, as proposed by Kalten-
Association 1995;274(22):1800 4.
born, but also the active and control subsystems may
Harryman DT, Sidles JA, Clark JM, Mcquade KJ, Gibb TD, Matsen
need to be considered when determining the direction of
FA. Translation of the humeral head on the glenoid with passive
the translational gliding movement of the humeral head.
glenohumeral motion. The Journal of Bone and Joint Surgery
It is suggested that clinical decisions of appropriate
1990;72A(9):1334 43.
Harryman DT, Sidles JA, Harris SL, Matsen FA. The role of the
gliding directions in the assessment and treatment of a
rotator interval capsule in passive motion and stability of the
patient with shoulder dysfunction should be considered
shoulder. The Journal of Bone and Joint Surgery 1992;74A(1):
carefully at this stage.
53 66.
+
Helmig P, SÅ‚jbjerg JO, Sneppen O, Lohr JF, Østgaard SE, Suder P.
References Glenohumeral movement patterns after puncture of the joint
capsule: an experimental study. Journal of Shoulder and Elbow
Surgery 1993;2:209 15.
Altman DG. Practical statistics for medical research. London: Chap-
Hess SA. Functional stability of the glenohumeral joint. Manual
man and Hall; 1996. p. 403 409.
Therapy 2000;5(2):63 71.
Apreleva M, Hasselman CT, Debski RE, Fu FH, Woo SLY, Warner
Hoepfl MC. Choosing qualitative research: A primer for technology
JJP. A dynamic analysis of glenohumeral motion after simulated
education researchers. Acrobat reader: 1 15. Retrieved May 28,
capsulolabral injury. A cadaver model. Journal of Bone and Joint
2002 from the World Wide Web: http://www.curriculum.edu.au/
Surgery 1998;80A:474 80.
tech/articles/choose.htm, 2002.
Baeyens JP, Van Roy P, Clarys JP. Intra-articular kinematics of the
Howell SM, Galinat BJ, Renzi AJ, Marone PJ. Normal and
normal glenohumeral joint in the late preparatory phase of
throwing: Kaltenborn s rule revisited. Ergonomics 2000;43(10): abnormal mechanics of the glenohumeral joint in the horizontal
1726 37. plane. The Journal of Bone and Joint Surgery 1988;70A(2):227 32.
Baeyens JP, Van Roy P, De Schepper A, Declercq G, Clarijs JP. Jadad AR, Moore A, Carroll D, Jenkinson C, Reynolds DJM,
Glenohumeral joint kinematics related to minor anterior instability Gavaghan DJ, McQuay HJ. Assessing the quality of reports of
ARTICLE IN PRESS
C. Brandt et al. / Manual Therapy 12 (2007) 3 11 11
randomized clinical trials: Is blinding necessary? Controlled with anterior instability or rotator cuff tearing. Journal of Shoulder
Clinical Trials 1996;17:1 12. and Elbow Surgery 1997;6(6):516 27.
Kaltenborn FM, Evjenth O. Manual mobilization of the extremity Panjabi MM. The stabilising system of the spine: part I Function,
joints. Basic examination and treatment techniques (I), 4th edn. dysfunction, adaptation and enhancement. Journal of Spinal
Oslo: Olaf Norlin Bokhandel; 1989. p. 26 27. Disorders 1992;5:383 9.
Karduna AR, Williams GR, Williams JL, Iannotti JP. Kinematics of   PEDro: Frequently asked questions  . PEDro 2003: 1 4. 5 March
the glenohumeral joint: influences of muscle forces, ligamentous 2003: http://www.pedro.fhs.usyd.edu.au/FAQs/faqs.htm
constraints, and articular geometry. Journal of Orthopaedic Poppen NK, Walker PS. Normal and abnormal motion of the shoulder.
Research 1996;14:986 93. The Journal of Bone and Joint Surgery 1976;58A(2):195 201.
Karduna AR, Williams GR, Williams JL, Iannotti JP. Glenohumeral Poppen NK, Walker PS. Forces at the glenohumeral joint in
joint translations before and after total shoulder arthroplasty. The abduction. Clinical Orthopaedics and Related Research 1978;135:
Journal of Bone and Joint Surgery 1997;79A(8):1166 74. 165 70.
Landis JR, Koch GG. The measurement of observer agreement for Rhoad RC, Klimkiewicz JJ, Williams GR, Kesmodel SB, Udupa JK,
categorical data. Biometrics 1977;33:159 74. Kneeland JB, et al. A new in vivo technique for three-dimensional
Loehr JF, Helmig P, SÅ‚jberg JO, Jung A. Shoulder instability caused shoulder kinematics analysis. Skeletal Radiology 1998;27:92 7.
by rotator cuff lesions: an in vitro study. Clinical Orthopaedics and Scholten-Peeters GGM, Verhagen AP, Bekkering GE, Van der Windt
Related Research 1994;304:84 90. DAWM, Barnsley L, Oostendorp RAB, et al. Prognostic factors of
MacConaill MA. The movements of bones and joints. The significance whiplash-associated disorders: a systematic review of prospective
of shape. The Journal of Bone and Joint surgery 1953;35B(2):290 7 cohort studies. Pain 2003;104:303 22.
[Chapter 5]. Thompson WO, Debski RE, Boardman III ND, Taskiran E, Warner
Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M. JJ, Fu FH, et al. A biomechanical analysis of rotator cuff deficiency
Reliability of the PEDro scale for rating quality of randomized in a cadaveric model. The American Journal of Sports Medicine
controlled trials. Physical Therapy 2003;83:713 21 Retrieved 1996;24(3):286 92.
January 14, 2004 from the World Wide Web: http://www.ptjour- Tugwell P, Brooks P, Wells G, Davies J, Shea B, De Bie R, et al.
nal.org/includes/printit.cfm, p. 1 9. Cochrane Musculosceletal Group. In The Cochrane Library, issue
Maitland GD. Vertebral manipulation. Oxford: Butterworth-Heine- 2. Oxford: Update software; 2003.
mann; 1998. p. 3 13. [Chapter 1]. Vaesel MT, Olsen BS, SÅ‚jbjerg JO, Helmig P, Sneppen O. Humeral
Mays N, Pope C. Quality in qualitative health research. In: Pope C, head size in shoulder arthroplasty: a kinematic study. Journal of
Mays N, editors. Qualitative research in health care. London: Shoulder and Elbow Surgery 1997;6(6):549 55.
British Medical Journal publishing group; 1999 [Chapter 9]. Verhagen AP, De Vet HCW, De Bie RA, Kessels AGH, Boers M,
McGlynn FJ, Caspari RB. Arthroscopic findings in the subluxating Bouter LM, et al. The Delphi list: a criteria list for quality
shoulder. Clinical Orthopaedics and Related Research 1984;183: assessment of randomized clinical trials for conducting systematic
173 8. reviews developed by Delphi consensus. Journal of Clinical
McMahon PJ, Debski RE, Thompson WO, Warner JJP, Fu FH, Woo Epidemiology 1998;51(12):1235 41.
SLY. Shoulder muscle forces and tendon exursions during Von Eisenhart-Rothe RMO, Jager A, Englmeier K-H, Vogl TJ,
glenohumeral abduction in the scapular plane. Journal of Shoulder Graichen H. Relevance of arm position and muscle activity on
and Elbow Surgery 1995;4(3):199 208. three-dimensional glenohumeral translation in patients with trau-
Meister K. Injuries to the shoulder in the throwing athlete. Part one: matic and atraumatic shoulder instability. The American Journal
Biomechanics/pathophysiology/classification of injury. The Amer- of Sports Medicine 2002;30(4):514 22.
ican Journal of Sports Medicine 2000;28(2):265 75. Williams GR, Wong KL, Pepe MD, Tan V, Silverberg D, Ramsey
Moher D, Jadad AR, Tugwell P. Assessing the quality of randomized ML, et al. The effect of articular malposition after total shoulder
controlled trials. International Journal of Technology Assessment arthroplasty on glenohumeral translations, range of motion, and
in Health Care 1996;12(2):195 208. subacromial impingement. Journal of Shoulder and Elbow Surgery
Mulligan BR. Manual Therapy:   NAGS  ,   SNAGS  ,   MWMS  , etc, 2001;10(5):399 409.
4th edn. Wellington: Plane View Services Limited; 1999. Winters JC, Jorritsma W, Groenier KH, Sobel JS, Meyboom-de Jong
Novotny JE, Nichols CE, Beynnon BD. Normal kinematics of the B, Arendzen HJ. Treatment of shoulder complaints in general
unconstrained glenohumeral joint under coupled moment loads. practice: long term results of a randomised, single blind study
Journal of Shoulder and Elbow Surgery 1998;7:629 39. comparing physiotherapy, manipulation and corticosteroid injec-
Oxman AD, Cook DJ, Guyatt GH. User s guides to the medical tion. British Medical Journal 1999;318(7195):1395 6.
literature: IV. How to use an overview. Journal of the American Woolf H. Evidence-based medicine and practice guidelines: an
Medical Association 1994;272(17):1367 71. overview. JMCC 2000;7(4):362 7.
Ozaki J. Glenohumeral movements of the involuntary inferior and Wuelker N, Korell M, Thren K. Dynamic glenohumeral joint stability.
multidirectional instability. Clinical Orthopaedics and Related Journal of Shoulder and Elbow Surgery 1998;7:43 52.
Research 1989;238:107 11. Wuelker N, Schmotzer H, Thren K, Korell M. Translation of the
Paletta GA, Warner JJP, Warren RF, Deutsch A, Altchek DW. glenohumeral joint with simulated active elevation. Clinical
Shoulder kinematics with two plane X-ray evaluation in patients Orthopaedics 1994;309:193 200.