Ed INVITED REVIEW

Shoulder & Elbow

2016, Vol. 8(1) 61–70
! The Author(s) 2016
Scapular dyskinesia: evolution towards Reprints and permissions:
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a systems-based approach DOI: 10.1177/1758573215618857
sel.sagepub.com

Elaine G Willmore1 and Michael J Smith2

Abstract
Historically, scapular dyskinesia has been used to describe an isolated clinical entity whereby an abnormality in position-
ing, movement or function of the scapula is present. Based upon this, treatment approaches have focused on addressing
local isolated muscle activity. Recently, however, there has been a progressive move towards viewing the scapula as being
part of a wider system of movement that is regulated and controlled by multiple factors, including the wider kinetic chain
and individual patient-centred requirements. We therefore propose a paradigm shift whereby scapular dyskinesia is seen
not in isolation but is considered within the broader context of patient-centred care and an entire neuromuscular
system.

Keywords
scapula, dyskinesis, shoulder, assessment, rehabilitation

Date received: 20th October 2015; accepted: 27th October 2015

as to how these could be incorporated and utilized in

Introduction
daily practice.
‘Optimal’ scapular motion is considered to be crucial to
the functioning of the shoulder and, as such, any alter-
ation in scapular kinematics is believed to be a contri-
What is normal and does it matter?
buting factor to the development of shoulder Scapulohumeral rhythm (SHR) is the co-ordination
pathology.1 In particular, any variation in the amount between humeral and scapular movements and was
of scapular upward rotation that occurs is particularly first described by Codman2 and subsequently popular-
implicated as a predisposing factor in the development ized by Inman.3 X-rays were used to calculate scapula
of shoulder symptoms. This is because the scapula must movement of seemingly one subject and the conclusion
upwardly and externally rotate and posteriorly tilt ade- reached that there was an overall constant scapulohum-
quately to prevent the humeral head from compressing eral rhythm of 2 : 1 during shoulder flexion and abduc-
and shearing against the under surface of the acromion: tion. Considering that a full arc of shoulder movement
one of the proposed mechanisms for producing the syn- is 180 , this is a result of 120 of glenohumeral move-
drome commonly referred to as subacromial impinge- ment and 60 of upward rotation.
ment. Based on this widely held view, the aim of many With the benefit of time and technology, it is clear
shoulder rehabilitation programmes is to correct aber- that SHR is much more complex than the reported 2 : 1
rant, local scapula mechanics.
The notion of scapular dyskinesis for the purposes of
the present review does not include presentations where 1
Gloucestershire Hospitals NHS Foundation Trust, Physiotherapy
there is a defined abnormality of the neuromuscular Department, Cheltenham General Hospital, Cheltenham, UK
2
system; for example, neuritis, neuropathy, neuropraxia College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
or other forms of peripheral nerve injury.
The purpose of the present review is to summarize Corresponding author:
Elaine Willmore, Physiotherapy Department, Cheltenham General
current concepts and provide the clinician with not only Hospital, Sandford Road, Cheltenham, GL53 7AN, UK.
a foundation of reasoning on which to base clinical Tel: þ0300 422 3040.
decision-making, but also some practical suggestions Email: elaine.willmore@glos.nhs.uk

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62 Ed Shoulder & Elbow 8(1)
ratio. Ratios are characteristically inconsistent, suggest- . Subjects identified by visual and three-dimensional
ing that the relationship is variable and nonlinear. In a tracking as having dyskinesis are no more likely to
survey of practicing physiotherapists which asked how report symptoms.23
reliable and valid they felt that the SHR theory is in
predicting pathological sequences in the shoulder com- There is also the problem of relevance. If the subject
plex Kirby et al.4 reported that 77% held the belief that of the measurement (in this case whether or not a scap-
it was reliable. The study by Kirby et al.4 therefore ula is dyskinetic) is a flawed concept, then the tests
demonstrates that SHR is a widely held belief and themselves are of limited use.
that physiotherapists therefore routinely make clinical
decisions based on principles that may lack validity.
Upward rotation is of course, just one component of
An improbable model?
scapula movement, with internal/external rotation and As has happened so many times in our profession, the
antero/posterior tipping occurring simultaneously original concept of a pure, delineated and possibly dog-
around three different axes. matic theory and its associated assessment has, over
If, as the evidence suggests, there is a wide range of time and with a growing body of research become ques-
physiological normal with high degrees of variability tionable. A recent consensus of assessment of visual
within and between individuals5,6 and populations,7 observation of scapula dyskinesis has further reduced
benchmarking ‘normal’ against ‘pathological’ poses a attempts to quantitatively assess scapula dyskinesis to a
considerable challenge. There are also variations of qualitative yes/no category.24
scapular movement within individuals depending on The traditional model of assessment of scapular dys-
the speed at which movement is performed,8 the load kinesis appears to be becoming more implausible
used,9 whether movement is concentric or eccentric10 (Table 1). The evidence challenging the existence of
and is performed unilaterally or bilaterally11 or even and the assessment for scapular dyskinesis is broad
the hand dominance of the subject.12 Against this back- based but, to compound matters, it would appear
ground, establishing what ‘abnormal’ is in the absence that attempts to correct identified scapular dyskinesis
of an accepted norm is a fundamental flaw in the trad- with rehabilitation are largely unsuccessful. McClure
itional concept. et al.25 found that shoulder impingement patients
with supposed scapular dyskinesis, as measured with
Assessing the ‘abnormal’ scapula: three-dimensional motion sensor equipment, had sig-
nificant improvements in their pain and function fol-
the traditional model lowing a 6-week exercise programme. The identified
Historically, there have been attempts to establish a dyskinesis, however, did not change. Similar results
threshold for what is and what isn’t a dyskinetic scap- were demonstrated in a more recent study by Struyf
ula such as the scapular lateral slide test.13 Tests have et al.26 that improvements in pain and function follow-
generally involved (i) quantitative measures of abnor- ing rehabilitation were not accompanied by alterations
mality or (ii) visual observation and a subjective judge- in the so-called dyskinetic movement.
ment by the clinician as to whether or not it is normal.
Although static and/or dynamic scapular asymmetry is
commonly integrated into clinical assessment, the col- Table 1. Challenges to the evidence regarding scapula
lective body of literature undermines its ubiquity. Both dyskinesia
quantitative and qualitative methods are of little clin-
ical value when it is considered that: In the absence of an identified normal, abnormal is an
unknown entity
. Postural asymmetries of greater than 1.5 cm are
What is perceived as abnormal may in fact be a normal
commonplace in asymptomatic individuals7,12
adaptation strategy
. Measurement is subject to measurement error and
observer bias14 Tests used to supposedly identified abnormalities cannot be
. No difference in scapular dyskinesis between symp- claimed to do so given that they lack construct validity
tomatic and asymptomatic shoulders have been
found across several studies15–17 Measurements are unreliable and prone to measurement
. Observed dyskinesis may actually be a strategy to error and bias
optimize certain individuals or cohorts18–20 A causal relationship between the existence of scapular
. Only low–moderate reliability and/or agreement is dyskinesis and the presence of symptoms cannot be
found between therapists regarding identification established
or categorization of dyskinesis21,22

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Ed Willmore and Smith 63

The whole concept of scapula dyskinesis as an iso- interventions aim to modify muscle activity around the
lated condition is therefore facing some kind of exist- shoulder with the intention of positively altering the
ential crisis. Perhaps it does not exist at all. pattern of muscular recruitment of the external rota-
tors, humeral head depressors and/or humeral head
adductors. If successful, the facilitation of these
Dissolve or evolve: the theory limps on?
muscle groups can be incorporated into early treatment
It would be remiss at this point to advocate the dissol- programmes.
ution of all things pertaining to aberrant scapula hum- As a result of its close association with the wider
eral rhythm and throw the baby out with the kinematic kinetic chain, techniques to reduce the appearance of
bathwater. Whether it is subjectively labelled as normal dyskinesis by incorporating elements chain activity (e.g.
or abnormal, what is observed is the association and single leg standing and standing on tip toes) have been
interdependence of the neuromusculoskeletal system used with demonstrably good effect.29 The use of iso-
around the trunk, shoulder girdle and wider kinetic metric glenohumeral external rotation with or without
chain. concurrent shoulder flexion as proposed by the SSMP
The end result should be production of smooth, con- can be easily applied with substantial affect. The exact
trolled movement between the humeral and scapula mechanism by which these procedures reduce symp-
components of movement and this requires significant toms is unknown but, clinically, it appears that, by
co-ordination. It is perhaps time to evolve our thinking accessing posterior rotator cuff activity via glenohum-
and move towards a systems-based approach. eral external rotation, a patient with what could be
During the course of movement, muscles almost described as visible scapular dyskinesis performs this
never work in isolation. Co-ordinated, controlled manoeuvre and, as far as the limitations of visual obser-
movement is the outcome of a functioning neuromus- vation allow, the dyskinesis significantly reduces or dis-
cular system. If something goes wrong with the move- appears altogether. If accompanied by a reduction in
ment, it could be attributed to any part of the system. pain, this would be a favourable response to the pro-
The complexity of this extraordinary process is reliant cedure. As mentioned previously studies by Tate et al.23
on an integrated process of sensoriomotor control. McClure et al.25 and Struyf et al.26 highlighted patient’s
Such control requires successful interaction of its com- outcome in terms of pain and function appears to be
ponent parts such as the motor cortex, thalmic system unrelated to changes in scapular kinematics. It is there-
and cerebellum, as well as higher cognitive functions fore not alterations to the appearance of dyskinesis per
such as perception.27 The interdependence of all of se that is the intended aim of the improvement tests but
these systems is underpinned by a vast network of neur- rather the reduction in reported symptoms that can be
onal circuitry, which is far from being understood. achieved with their use.
The fact that such a spectrum of different interven-
Scapula assessment revisited: if you can tions all have the potential to reduce the dyskinesis
introduces another thought dimension. If multiple
affect it, suspect it
and varying actions all have the potential to ‘correct’
The very nature of the complexity and the interdepend- the scapular dyskinesis, then there can be no single
ency of all the systems required for motor control mechanism by which said scapular dyskinesis occurred
render the existence of a litmus test for the presence in the first instance. Subgroup analysis of which type of
of scapular dyskinesis extremely unlikely and the patients respond best to which type of intervention
search for one a potentially fruitless task. Over the would be revealing. However, no such predictive meas-
last decade, there has been a gradual move in the assess- ures have been validated and clinicians do not have the
ment of musculoskeletal conditions from the limited luxury of waiting until they are.
value of the traditional orthopaedic test toward a In an attempt to signpost therapists or indeed our
more global, systems-based approach. The publication surgical colleagues, the assessment tools in Fig. 1 are
of the shoulder symptom modification procedure suggested as a starting place to attempt to find an inter-
(SSMP)28 signalled a paradigm shift in the way shoul- vention that affects either the patient’s symptoms that
der assessment was conducted. This approach involves may include pain and/or instability.
subjecting patients with shoulder pain to a series of
independent manoeuvres in an attempt to reduce the
patient’s numerical symptom rating scale by 30%.
Making sense of the assessment
Such interventions include thoracic (postural) correc- If these ‘improvement’ or ‘symptom modification’ pro-
tion, scapula movement facilitation, humeral head pro- cedures have a significant effect on symptoms, they
cedures and neuromodulation procedures. The muscle could be used at the starting point for rehabilitation
contraction element of the humeral head and scapula and exercise prescription. However, some elements are

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64 Ed Shoulder & Elbow 8(1)
Clinical Applicaons of a Symptoms and Systems based assessment

Apparent Scapula Dyskinesis observed

Potenal intervenons

Humeral Head Scapula Facilitaon External Rotaon External Rotaon Single leg standing Tip toe standing Gym ball sing
Facilitaon (stac) (dynamic)

Reducon in symptoms

Incorporate into treatment plan

Figure 1. Potential symptom modification procedures.

easier to integrate than others. For example, if dynamic produce the upward rotation, posterior tilting and exter-
external rotation or tip toe/single leg standing reduces nally rotate necessary for optimal movement and func-
the symptoms or the appearance of dyskinesis, then this tion.30 A high correlation therefore exists between the
can easily be used as a foundation on which any number action of scapulohumeral and axioscapular muscles
of other exercises functionally relevant to the patient can and activity in one group does not exist without corres-
be built. If, however, humeral facilitation or scapular ponding activity in the other.
upward rotation improves the patients symptoms, then Just like the rotator cuff, scapula muscles have mul-
this is less straightforward. Scapular upward rotation is tiple roles which vary, dependent on the task, the load,
not a movement that exists in isolation and the transla- the speed or the range in which the movement is occur-
tional anterior posterior glide movement of humeral ring.30 At any time, dependent on these factors, any
head facilitation requires an externally applied pressure. part of the rotator cuff, other scapulohumeral or axios-
The challenge then becomes finding an exercise that capular muscles could be acting in an agonist, antag-
capitalizes on the symptom reduction achieved during onist, stabilizing (static or dynamic) or synergistic
symptom modification. For this, clinical reasoning function (Table 2). Glenohumeral external rotation
needs to take one step further and this is significantly exercises, for example, are classically regarded as work-
aided by understanding the roles and function of the ing the rotator cuff in its agonist role. This is true, but it
scapula and rotator cuff. is also true of all shoulder rotator torque generators
and is therefore not specific to the rotator cuff.
Glenohumeral external rotation however also requires
Understanding the functional anatomy
the scapular muscles to function in their stabilizing role,
When glenohumeral movement occurs, the scapula explaining why either static or dynamic rotation uti-
must also move to allow the repositioning of the glen- lized through symptom modification procedures can
oid fossa thus increasing the available range of move- change apparent scapula dyskinesis.
ment. During this movement, the scapulohumeral and In addition to their agonistic role specific shoulder
axioscapular muscles must collectively function to muscles also stabilize against destabilizing forces cre-
maintain optimal mechanical alignment. Rotator cuff ated by other shoulder muscles but this is far from
activity prevents unwanted humeral head translation static. Rotator cuff muscles prevent unwanted transla-
but, when left unchecked, would pull the scapula lat- tion of the humeral head caused by other humeral mus-
erally, essentially creating a destabilizing force. The cles (e.g. deltoid and pectoralis major). Axioscapular
axioscapular muscles respond by preventing the scapu- muscles work against the destabilizing force of the sca-
lohumeral muscles from destabilizing the scapula and pulohumeral muscles to prevent the scapulohumeral

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Ed Willmore and Smith 65

Table 2. The varying roles of muscles Mobilising role

Is the scapula
and/or rotator cuff Static
Type Role working in a:-
Stabilising role
Agonist Mover: prime or assistant mover
Dynamic
Antagonist Muscle which must relax or work
eccentrically to allow the Figure 2. Assessment findings and treatment planning.
desired movement to occur

Stabilizer Muscle that supports a body part

so that another muscle will have
a firm base from which to act
Mid range
Synergist Muscle that eliminates an
undesired movement that
would otherwise be produced
by the mover(s) and
stabilizer(s) Posterior/Anterior cuff Posterior/Anterior cuff
Inner/Outer range Inner/outer range

Scapulohumeral muscles Figure 3. Through range assessment of the rotator cuff. The
scapula is stabilized and therefore not working in its dynamic
Rotator cuff role.
Deltoid

Teres major
Scapula dyskinesis observed
Long head of triceps

Axioscapular muscles
Posive response with humeral head facilitaon
Trapezius

Levator scapulae

Rhomboid major þ minor Weakness idenfied in the posterior cuff in its inner range

Serratus anterior

Pectoralis minor
Paent cannot achieve full
Paent can achieve
Axiohumeral muscles internal rotaon without
full internal
compensatory shoulder
Pectoralis major rotaon
girdle protracon

Latissimus dorsi

Consider exercises
muscles from translating the scapula off the thoracic to target the Either:-
cage. To rehabilitate the stabilizing function of the posterior rotator Scapula is not stabilising
axioscapular muscles (and also, by virtue of their inter- cuff with a stac, stacally effecvely OR
dependence, the rotator cuff), it is perhaps more useful progressing to The rotator cuff is unable
to consider strategies that allow the shoulder complex dynamic scapula to fulfil its mobilising role
in its inner range
to react to de-stabilizing forces.30 requirement
If a particular movement cannot be performed with-
out apparent scapula dyskinesis, it is worth considering Figure 4. Assessment reasoning.
that the cause of this is not ‘weakness’ and inability
of, for example, the serratus anterior to perform its activation of serratus anterior in the early stages
agonistic role but the inability of the scapular and/or of movement has been implicated as a potential source
rotator cuff muscles to work simultaneously in both of scapula dyskinesis in patients with shoulder symp-
their mobilizer and dynamic stabilizing roles. Delayed toms.17,31 Data from these studies have indicated that

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66 Ed Shoulder & Elbow 8(1)

Figure 5. The dyskinesis of this breakdancer disappears with closed chain loading.

such movement lag has normalized before 90 , which is to find at least one exercise that a patient can leave
outside the range of the painful arc classically associated with, empowered by the knowledge that they can
with impingement type symptoms. Although conjecture, affect their own symptoms with movement.
there is speculation that any increased rate of upward As previously noted, it is difficult to justify a position
rotation and/or posterior tipping to overcome latency of claiming that a patient is undergoing rotator cuff or
contributes to the appearance of dyskinesia. scapula specific rehabilitation. To suggest that a par-
When interpreting assessment findings it is perhaps ticular exercise is purely a ‘scapula stability’ exercise
helpful to consider the process outlined in Fig. 2. may not only be difficult to substantiate based on the
Given their interdependence, a thorough assessment research evidence,32 but also is contradictory to the
of the rotator cuff should also be conducted (Fig. 3) to functional anatomy of the region. What one exercise
complement the scapula assessment. may do more than another, however, is bias the exercise
If weakness of a portion of the rotator cuff is found, towards a situation where, for example, the scapula is
together with the findings from symptom modification only working in a static stabilizing, rather than a
tests, a clearer picture about where to start with dynamic stabilizing role, where the former is generally
rehabilitation may start to materialize. An example of considered an easier or less complex task.
this process is shown in Fig. 4. The interdependence of the scapula, rotator cuff and
The kinetic chain elements of assessment should not kinetic chain requires clinicians to question the desirabil-
be forgotten. Single leg standing or tip toe standing ity of isolating one part of the system from the other. If
may not have resulted in the most significant change the scapular and rotator cuff components are required to
with symptom modification but they remain a signifi- work together functionally, they should be trained as
cant part of the bigger picture. If the humeral contin- such. ‘Scapula specific rehabilitation’ may sound impres-
gent of the system is unable to perform a pattern of sive but, unless you are engaged in an activity that does
movement without the involvement of the scapular not involve any movement of the humerus, it is in all
muscles, the scapula is unfairly implicated as the culprit likelihood an unobtainable goal. Furthermore, it is also
when it is being utilized in an unconventional way in an not possible to isolate single muscles within a single exer-
attempt to maintain function. Similarly, the dyskinesis cises. Even activities that demonstrate maximum activa-
may not become apparent until the task becomes more tion do not do so to the exclusion of other muscles.33
complicated and involves co-ordination with the wider These lessons have been learned and are well supported
chain. Patients may also present differently in an open with multiple investigations into both exercise and the
or closed chain position (Fig. 5). In either case, the overwhelming number of supposed specific manual
observed result is faulty and inefficient motor patterns muscle tests that are proposed for the identification of
may be the cause, or equally the response, of pain and/ specific shoulder pathology.34 Because it is almost impos-
or weakness elsewhere in the system. sible and generally undesirable to isolate individual mus-
cles, the case for integration strengthens.
Rehabilitation: isolate or integrate?
The key to success with this approach to rehabilitation
Linking assessment to rehabilitation
is having a sound appreciation of what the scapula and The flowchart in Fig. 4 illustrates how assessment find-
rotator cuff muscle groups are doing with each exercise, ings may influence the clinicians decision-making pro-
why they may or may not be beneficial, and how to cess. The exercises pictured in Fig. 6 are not intended to
adapt them if the patient is unable to perform them be prescriptive but, instead, they illustrate how different
without compensatory movements or symptoms. With exercises or progressions can influence the relative con-
this knowledge and armed with some clinical reasoning, tributions from the scapula, rotator cuff and kinetic
creativity and often trial and error, it should be possible chain.

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Ed Willmore and Smith 67

Figure 6. Potential early exercises dependent on response to symptom modification.

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68 Ed Shoulder & Elbow 8(1)
Treatment
Assessment

Tradional Symptom & Systems Tradional Symptom & Systems

•Isolated •Global •Independent from • Informed by
•Populaon specific •Valid across assessment findings assessment findings
•Postural Asymmetry populaons Stac •Dynamic
•Lateral slide test Symptom modificaon •Scapula “seng” •Symptom driven
•Visual observaon procedures including: •UFT “inhibitory” •Funconal integraon
•Biomechanical model •Humeral head techniques i.e. taping of the rotator cuff,
•Scapula facilitaon •Aim is to change or scapula & kinec chain
•Trunk posion correct scapular •Paent centred
•Acvaon of the posion i.e. •Progression focuses on
kinec chain biomechanically driven increasing complexity
•Strength changes •Progression focuses •Propriocepvely
across varying on increasing strength mediated
posions

Interdependence
of Rx and Ax

Figure 7. Scapular dyskinesis: traditional model versus a symptoms and systems-based approach.

Strength or motor control? kinetic chain necessary for that particular movement
Over recent years, there have been a wealth of studies pattern. For the shoulder, this will require assessment
utilizing electromyographic (EMG) data.35–39 With of the constituent parts working in both their agonist
such a plethora of such information now available in and stabilizer roles throughout full ranges of both con-
the literature, an unintended consequence of this may centric and eccentric phases of movement. It will also
be that there has been an unwitting over emphasis on necessitate involvement of the wider kinetic chain to
EMG output and equating it with strength. The trad- train relevant motor patterns that resemble the func-
itional model of scapular assessment relies on increas- tional demands of the patient. In the early stages of
ing strength by progressing through a rainbow of rehabilitation, it may be necessary to limit the
theraband resistance and inhibitory techniques for sup- number of simultaneous functions that the patient is
posed ‘over active’ muscles such as taping, trigger point required to perform. Low load, unsupported shoulder
release or massage. Exercise progression using a sys- rotation tasks can be used to train complex normal
tems-based approach would instead focus not on bio- motor patterns; therefore, the early part of the motor
mechanically correcting the scapula position but, pattern can be recruited and retrained in the appropri-
instead, on regaining and retraining the whole motor ate manner. As rehabilitation progresses, the patient
control pattern that had been identified through careful is challenged to maintain the correct motor pattern
assessment, in terms of being problematic for that despite the increasing demand and complexity of the
patient (Fig. 7). relevant task. This may involve elements of speed,
co-ordination, load and specific functional require-
ments relevant to the individual, until a normal, fully
Conclusions
functioning motor control pattern can be established
A functioning proprioceptively mediated motor control and, crucially, reinforced with repetition. By utilizing
system requires co-ordination, and therefore integra- the fundamental principles of motor learning and skill
tion, of all the different body parts throughout the attainment with what is understood about

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Ed Willmore and Smith 69

proprioceptively mediated musculoskeletal rehabilita- 12. Koslow PA, Prosser LA, Strony GA, Suchecki SL and
tion, we can use our skills to their full potential. The Mattingly GE. Specificity of the lateral scapular slide test:
coalescence of assessment and treatment techniques a reliability and validity study. Phys Ther 2003; 81:
results in a symptoms and systems approach that is 799–809.
13. Kibler WB. The role of the scapula in athletic function.
patient-centred and relevant to the functional require-
Am J Sports Med 1998; 26: 325–37.
ments of the individual. We advocate that this has 14. Hayes K, Walton JR, Szomor ZL and Murrell GAC.
advantages over a traditional biomechanical model Reliability of 5 methods for assessing shoulder range of
that utilizes assessment principles focused on minute motion. Aust J Physiother 2001; 47: 289–94.
differences in centimetres and degrees and deviations 15. Nijs J, Roussel N, Vermeulen K and Souvereyns G.
from a normal that arguably do not exist. Scapular positioning in patients with shoulder pain: a
study examining the reliability and clinical importance
of 3 clinical tests. Arch Phys Med Rehabil 2005; 86:
Declaration of conflicting interests 1349–55.
The author(s) declared no potential conflicts of interest with 16. Lukasiewicz AC, McClure P, Michener L, Pratt N and
respect to the research, authorship, and/or publication of this Sennett B. Comparison of 3-dimensional scapular pos-
article. ition and orientation between subjects with and without
shoulder impingement. J Orthop Sports Phys Ther 1999;
29: 574–86.
Funding
17. Graichen H, Stammberger T, Bonél H, et al. Three
The author(s) received no financial support for the research, dimensional analysis of shoulder girdle and supraspinatus
authorship, and/or publication of this article. motion patterns in patients with impingement syndrome.
J Orthop Res 2001; 19: 1192–8.
18. Kardua AR, Kerner PJ and Lazarus MD. Contact forces
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