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Observe the level of the acromion on both sides, and look for difference in height between them. Also assess the level of the superior and inferior borders of the Scapula to notice any height difference between them

Muscles that are most likely to be affected with an elevated shoulder:

  • Levator Scapulae
  • Trapezius
  • NB! To differentiate between Levator Scapulae and Trapezius, note that Levator Scapulae affects the Scapula, and if there is a shortening in this muscle then the lower angle of the Scapula will be elevated

It is important to note that sometimes the level difference between the shoulder might not be from one side being elevated, but rather the opposite side is depressed

Muscles that are most likely to be affected with a depressed shoulder:

Another useful way to detect shoulder height difference is by observing any height level difference between the olecranons of the elbows. Note though, that this might also be due to lateral flexion of the trunk and not only due to shoulder height difference.


Observe the medial and lateral border of the scapulae, if the scapulae is abducted away from the spine, it is rotated in an upward rotation. If the scapulae is adducted towards the spine it is rotated in a downward rotation

Muscles which are most likely to be affected with an upward rotated scapula:

Muscles which are most likely to be affected with an downward rotated scapula:


It is important to note that often it is not only a protraction of the Scapula when this occurs, but it is often accompanied with internal rotation of the shoulders as well.

Observe the patient from the lateral side, and notice the position of the shoulders compared to the ear and neck. If they are drawn to the front of these structures, consider the following patterns and their muscles:

Protracted shoulders

Internal rotation of shoulder