80 Original article

Inter-rater and intra-rater reliability of Kinovea software for

measurement of shoulder range of motion a a b
Reham M. Abd Elrahim
a
, Eman A. Embaby , Mohamed F. Ali ,
Ragia M. Kamel
a
Department of Basic Science, Faculty of Background
Physical Therapy, Cairo University, Giza, Goniometry is a tool used frequently for measuring and documenting range of
b
Department of Orthopedics, Faculty of
Physical Therapy, 6th Octobre University, motion (ROM) during a physical therapy examination. With modern innovations in
Cairo, Egypt technology, new methods other than the universal goniometer have been applied.
Kinovea software is a recent video-based method that uses a virtual goniometer to
Correspondence to Eman A. Embaby, PhD,
2108, Street Arqam, Merag City, Maadi, Cairo, obtain values for the ROM of joints. However, the software’s reliability in measuring
11931, Egypt, Tel: + +20 100 522 0648; shoulder joint ROM has not been studied.
e-mail: eman_ahmed@cu.edu.eg Purpose
Received 24 March 2016 This study was conducted to investigate the inter-rater and intrarater reliability of
Accepted 14 June 2016 Kinovea software for measuring shoulder joint ROM in healthy individuals.
Bulletin of Faculty of Physical Therapy Materials and methods
2016, 21:80–87 Shoulder joint ROM was measured in 52 healthy individuals (mean±SD age was
26.7±4.2 years) using Kinovea photographic measurements by three trained raters.
Intrarater reliability was examined by a single rater within the same day. Shoulder
flexion, abduction, and external and internal rotation ROM were measured with the
patient in supine position.
Results
The inter-rater reliability ranged from an intraclass correlation coefficient value of
0.95 to 0.98, whereas the intrarater reliability ranged from an intraclass correlation
coefficient value of 0.98 to 0.99.
Conclusion
This study showed highly reliable shoulder joint ROM measurements in healthy
adults using the Kinovea software.

Keywords:
goniometry, movement, photography, reliability, upper limb
Bulletin of Faculty of Physical Therapy 21:80–87
© 2016 Bulletin of Faculty of Physical Therapy
1110-6611

universal goniometry) to electromagnetic tracking

Introduction
systems to the most technologically advanced, high-
Daily activities such as drinking, eating, washing, and
cost tools (3D and 4D motion analysis equipment with
brushing depend on motions of the upper extremities
sensors fixed on the scapula) [7–12]. Traditionally,
[1]. The upper extremities make up a mechanically
ROM assessment is carried out using goniometers or
linked unit, and any immobility of one part of that unit
inclinometers [12,13].
has a negative impact on the entire upper extremity unit
[2]. The shoulder has the most mobility in the body,
Goniometers are easy to apply, low in cost, and do not
and it allows for orientation of the upper extremities as
require data reduction [14]. One major drawback of
required [3]. The assessment of shoulder range of
these traditional ROM assessment methods is that the
motion (ROM) is considered crucial for diagnosing
appropriate application depends on the examining
disorders of the shoulder and for evaluating the
clinician who has the potential for error, especially
rehabilitation procedures that may influence shoulder
when dealing with the complexities of the shoulder
function [4,5].
joint [15]. The reference arm of the goniometer should
be fixed by the clinician’s hand while the goniometer’s
During clinical settings, an active range of motion
other arm rotates with the movement of the measured
(AROM) assessment is used to assess movement
and state of function of an impaired upper extremity
[6]. A review of the literature revealed articles showing This is an open access article distributed under the terms of the Creative
Commons Attribution-NonCommercial-ShareAlike 3.0 License, which
different tools used for measuring the ROM of joints of allows others to remix, tweak, and build upon the work
the human body. These tools ranged from easy, noncommercially, as long as the author is credited and the new
inexpensive tools (such as visual estimation and the creations are licensed under the identical terms.

© 2016 Bulletin of Faculty of Physical Therapy | Published by Wolters Kluwer - Medknow DOI: 10.4103/1110-6611.196778
 Reliability of Open-source software Abd Elrahim et al. 81

joint. This is not easy in some situations, such as a flexion, abduction, and ERs and IRs were evaluated
shoulder internal rotation (IR) and external rotation with the patient in supine position by three raters.
(ER) at 90° of abduction in which the reference arm Intrarater reliability was examined by a single rater
does not refer to a bony landmark [12]. within the same day.

A more detailed and extensive measurement of joint Study sample

mobility can be obtained with motion capture systems The sample size calculation was carried out based on the
using active or passive markers [16–19]. These systems work of Walter et al. [28]. For intraclass correlation
are suitable for biomechanics or motion analysis coefficient (ICC), sample size estimation was based on
laboratories more than therapy clinics because of the an α value of 0.05, a β value of 0.20, and an expected ICC
systems’ large cost and space requirements that often value (intrarater and inter-rater reliability) of 0.90, with
hinder their usefulness in a clinical setting [15,20]. An the minimum value in the one-sided 95% confidence
ideal measuring system is one that is inexpensive and interval (CI) of 0.80, using two replicates of each
can be used easily without the need for sensors attached measurement and three evaluators. Using these
to the body [21]. parameters and defining the unit of assessment being a
shoulder, the estimated sample size required ∼46
Kinovea is a free software used for the analysis, shoulders to be assessed. Allowing for losses, 55
comparison, and evaluation of sports and training. It healthy individuals were invited to participate in the study.
is also suitable for physical education teachers and
coaches [22]. Kinovea has many advantages; it is This study was conducted in Al-Haram Hospital,
easy to use and does not require physical sensors Giza, Egypt. The population included in this study
during the analysis [21]. In addition, the software was a convenient sample. Participants were recruited
can be used as a measurement tool for motion among volunteers from the surrounding community
analysis. Kinovea was used in previous studies to (staff and students). They were verbally asked to
measure the kicking actions of Taekwondo athletes participate in the study. Healthy adults who had a
[23], to measure the position, velocity, and acceleration full ROM of the shoulder girdle and shoulder joints
of the lower limbs in healthy participants [21], and to and had no previous history of musculoskeletal
measure the foot strike angles of novice runners [24]. or neurological problems of the dominant upper
extremity were included in the study. Their
Recently, the validity and reliability of the Kinovea BMI ranged from 18 to 25 kg/m2. We excluded
software for measuring the flight time and height of participants with dominant upper limb or scapular
vertical jumping were studied by Balsalobre-Fernández pathology or surgery. Of the 55 invited participants,
et al. [25]. In addition, the reliability of Kinovea software 52 (31 male and 21 female) met the inclusion criteria
in measuring the normal resting facial distances and and were selected for the study. Thus, 52 shoulders
maximal excursions of the selected markers during were assessed by the three raters, with a total of 156
facial movements was investigated by Baude et al. measures. In this study, participants’ mean age±SD was
[26]. Furthermore, Moral-Muñoz et al. [27] stated 26.7±4.2 years, the mean height±SD was 167.8±9 cm,
that Kinovea software is a highly reliable tool that and the mean weight±SD was 68.9±7.2 kg. The
offers an objective method for evaluating hamstring dominant side was tested. The right side was the
flexibility. However, the reliability of Kinovea dominant side in 47 participants and the left side in
software for measuring shoulder joint ROM has never five participants.
been studied. Thus, the purpose of this study was to
assess the inter-rater and intrarater reliability of Kinovea Raters
software in measuring shoulder flexion, abduction, and Three raters (A, B, and C) who completed a short
ER and IR ranges in healthy individuals. training (2 h) on the method participated in the study.
All raters were physiotherapists with more than 5 years
of clinical experience in orthopedic physical
Materials and methods examination and goniometry (rater A had 20 years
Design of the study of experience, rater B had 12 years of experience,
A cross-sectional observational study was used to and rater C had 8 years of experience).
determine the reliability of Kinovea software (version
0.8.15, available for download at: http://www.kinovea. Procedures of the study
org). Active ROM of four shoulder joint movements This study was approved by the Faculty of Physical
was evaluated using the Kinovea software. Shoulder Therapy Ethics Committee, Cairo University, Egypt.
82 Bulletin of Faculty of Physical Therapy, Vol. 21 No. 2, July-December 2016

Participants were informed about the purpose and movements. Once positioned, the participant was asked
procedures of the study before their written consent to rotate the arm back into ER to their available end-range
was obtained. Randomization was carried out by asking without any discomfort. The participant was instructed
the participants to draw a folded paper that was labeled not to lift the lower back during this measurement.
with the tested movement from a box.
IR-AROM: IR-AROM was measured following the
Participants were asked to wear light clothing to allow same procedure used for ER, except that the parti-
for better identification of the bony landmarks and cipant was instructed to internally rotate the arm while
to avoid motion restrictions. Before recording any maintaining the 90° abducted position.
measurement, the tested movements were practiced
three times to familiarize the participants with the Instruments
procedure and the motions being measured. Images of each participant were captured using a digital
camera (Nikon Coolpix S3200, effective pixels 16 MB;
Before photographing the motion, a pen marker was Nikon Corp., Tokyo, Japan) to capture the sagittal and
used to draw cross marks on preselected anatomical the frontal plane profile of the dominant shoulder. The
landmarks on the tested dominant upper limb camera was placed 1.5 m away from the participants on
(acromion process, coracoid, olecranon process, and a tripod at a height of 80 cm. To maintain the same
the lateral epicondyle, midthoracic line, and midshaft distance between the camera and the participants; the
of the humerus). Using these marks, we quantified the tripod was placed on taped markers on the floor. All
following four movements that each participant images were imported into a laptop and analyzed
performed at a maximum (end-range) joint movement using Kinovea software, which is a free, open-source
at each participant’s own pace: software created for movement analysis (Kinovea,
0.8.15, http://www.kinovea.org/).
Flexion-AROM: a cross mark was placed on the lateral
aspect of the center of the humeral head approximately Raters were told to view each image only once so that
below the acromion process (fulcrum). One cross mark they would not change their assessment. Each rater
was placed along the midshaft of the humerus aligned took two measurements of every participant, and each
with the greater tuberosity and lateral epicondyle of the rater repeated the assessment 1 week later. On the
humerus; one additional cross mark was placed along the second day of the analysis, the order of appearance of
midline of the thorax [29]. Flexion-AROM was assessed the images on the computer screen was randomized by
with the participant in supine position on a standard an assistant to minimize any learning or order effects.
plinth. The arm was actively elevated in a strict sagittal All raters were blinded to the results of each other
plane with the thumb pointed up toward the ceiling. and to their own consecutive repeated results. The
intratester reliability phase of the study was conducted
Abduction-AROM: a cross mark was placed on the by one single rater (rater C) by measuring joint ROM of
coracoid process (fulcrum). One cross mark was placed the same participants twice within the same day (with a
along the shaft of the humerus, and an additional cross period of 3 h in between).
mark was placed along the midline of the thorax [29].
Abduction-AROM was measured with the participant Data analysis
in the supine position, as in flexion-AROM. The arm All movements were converted into angles using the
was actively elevated in the strict coronal plane with the virtual goniometer of the software.
thumb pointed up toward the ceiling. This allowed for
the required ER necessary to avoid impingement of the Flexion-AROM
greater tuberosity on the acromion process. To measure shoulder flexion angle, a line was drawn
from the fulcrum point to bisect the midthorax line
ER-AROM: a cross mark was placed at the olecranon (stationary arm). Another line was drawn bisecting the
process (fulcrum), and another cross mark was placed at point demarking the midshaft of the humerus (movable
the ulnar styloid process [29]. ER-AROM was tested arm). The angle of the intersection of the two lines was
with the participant in supine position. The tested arm measured in degrees (Fig. 1).
was supported on the table at 90° abduction, the elbow
was flexed to 90°, and the wrist was neutral. A towel roll Abduction-AROM
was placed under the humerus to ensure neutral horizontal To measure shoulder abduction angle, a line was drawn
positioning and to approximate the plane of the scapula, from the fulcrum point bisecting the point of the
and a weighted bag was used to prevent unwanted scapular midthorax line (stationary arm), and another line
 Reliability of Open-source software Abd Elrahim et al. 83

bisected the point demarking the shaft of the humerus values were between 1.7° (ER) and 2.1° (abduction
(movable arm). The angle of the intersection of the two and IR) (Table 3). Overall, measurements taken
lines was measured in degrees (Fig. 2). in flexion and ER showed the potentially lowest
and highest meaningful reliability properties,
ER-AROM respectively.
The ER angle was formed by a line drawn from the
Figure 1
fulcrum point through the shaft of the ulna (movable
arm) and a line perpendicular to the plinth (stationary
arm) (Fig. 3).

IR-AROM
The same procedure was used to measure the ER of the
shoulder (Fig. 4).

Statistical analysis
Descriptive data analyses were calculated as well as
the relative reliabilities and 95% CIs were expressed
as the ICC3,1 and inter-rater correlation coefficients
(ICC2,2). All statistical analyses were carried out using Analysis of shoulder flexion.
the statistical package (SPSS for Windows, version 20;
SPSS Inc., Chicago, Illinois, USA). The reference Figure 2
ranking values for the ICC in the present study were
those described by Johnson and Gross [30]: small
reliability, 0.25; low reliability, 0.26–0.49; moderate
reliability, 0.50–0.69; high reliability, 0.70–0.89; and
very high reliability more than 0.90. Absolute reliability
was expressed as a standard error of measurement
(SEM). Further, the minimal detectable change
(MDC), which represents the magnitude of change
necessary to exceed the measurement error of two
repeated measurements at a specified CI, was
calculated for the 95% CI (MDC95).

Results Analysis of shoulder abduction.

The descriptive statistics (mean±SD) of inter-rater
and intrarater measurements using Kinovea software
are shown in Tables 1 and 2, respectively. The Figure 3
ICCs2,2 for inter-rater reliability of shoulder joint
measurements ranged from 0.95 (0.92–0.97) for ER
to 0.98 (0.97–0.99) for abduction with the error of
measurement between raters ranging from 0.92°
(ER) to 1.6° (abduction) (Table 3). The MDC95
values were between 2.6° (ER) and 4.4° (abduction)
(Table 3). Overall, measurements taken in abduction
and ER showed the potentially lowest and highest
meaningful reliability properties, respectively. The
intrarater reliability of the measurements made
with Kinovea software was verified with ICC
values for shoulder measurements ranging between
0.98 (0.98–0.99) for flexion and 0.99 (0.98–0.99) for
other movements (Table 3). The SEM was small
for shoulder ROM in all directions (Table 3), ranging
Analysis of shoulder external rotation.
from 0.61° (ER) to 0.77° (IR). The MDC95
84 Bulletin of Faculty of Physical Therapy, Vol. 21 No. 2, July-December 2016

Figure 4 before testing to become familiar with the software

and to increase the accuracy of their analyses. This
was carried out in accordance with the recom-
mendation of Baude et al. [26], who suggested
that formal training session for patients and raters
be taken to improve the reliability of Kinovea in the
motion analysis of facial muscles other than the
frontalis muscles.

Furthermore, in the current study, a cross mark was

drawn on the skin to identify the joint fulcrum (center
of motion) as a practical method to increase the
reliability of the study. This is in agreement with
the procedure by Baude et al. [26], who used face
paint to draw dots on the face of each participant on
Analysis of shoulder internal rotation.
preselected anatomical facial markers. In addition,
Richardson [24] placed athletic tape markers on
participants’ shoes to assist in digitizing the foot
Table 1 Descriptive statistics (mean±SD) of inter-rater
strike angles of novice runners, and Damsted et al.
measurements
[31] used a hip marker to quantify knee and hip angles
Joint movement Inter-rater measurement (deg.)
at the foot strike during running. Furthermore, Moral-
Rater A Rater B Rater C
Muñoz et al. [27] marked the participants’ skin to
Shoulder flexion 163.9±6.8 164.2±6.9 164.4±6.5 measure hip and knee joint angles as measurements
Shoulder abduction 95.7±7.3 96.1±7 96.5±7.1
of hamstring flexibility.
Shoulder ER 96.7±7 97.1±7 97±7.2
Shoulder IR 101.7±6.6 101.7±6.5 102.3±6.7
Kinovea is a video analysis software with a built-in
ER, external rotation; IR, internal rotation.
angle selection tool that eliminates the need to print
Table 2 Descriptive statistics (mean±SD) of intrarater out still photos and uses a digital virtual goniometer to
measurements measure the joint angles with a precision of 1°
Joint movement Intrarater measurement (deg.) increments [24,32]. Accordingly, it is considered a
First measurement Second measurement photography-based goniometry that differs from a
Shoulder flexion 164.4±6.1 164.5±5.9 clinical goniometry with its drawbacks of fixing the
Shoulder abduction 95.8±7.2 95.8±7 goniometer on the patient to measure the ROM of
Shoulder ER 96±7.4 96.1±7.2 joints.
Shoulder IR 102.3±6.7 102.2±6.7
ER, external rotation; IR, internal rotation. The findings of the current study revealed that the
ICCs for inter-rater reliability of shoulder joint
Discussion measurements ranged from 0.95 to 0.98, which
This study shows that the video-based measuring exceed those reported by Mullaney et al. [12]. They
method of shoulder ROM using Kinovea software studied the intrarater and inter-rater reliability of a
applied on plain video recordings of shoulder joint construction grade digital level compared with the
movements is highly reliable within and between standard universal goniometer for measurements of
raters. Compared with 2D analysis studies, Kinovea active assisted shoulder ROM in patients with
software is free, open-sourced, fast to use, and shows unilateral shoulder pathology. They found that inter-
very good advantages in terms of its applicability in rater ICCs ranged from 0.62 to 0.79 for the goniometer
clinical settings. In addition, it could be frozen at the and from 0.31 to 0.87 for the digital level in the
appropriate time of joint ROM (http://www.kinovea. measurement of the noninvolved limb.
org/) [25,26].
With regard to intrarater reliability, measurements
Previous literature on Kinovea reported that this with Kinovea software were found to be comparable
method does not require prior experience in video to the findings of Mullaney et al. [12], who reported
recording and analysis to obtain highly accurate and that ICC values ranged from 0.91 to 0.99 for both the
reliable measurements [21,25]. However, in the goniometer and the digital level. In addition, Kolber
current study, raters attended a training session et al. [13] investigated the intrarater reliability of
 Reliability of Open-source software Abd Elrahim et al. 85

Table 3 Indices of inter-rater and intrarater reliability

Joint movement Inter-rater reliability Intrarater reliability
ICC2,2 (95% CI) SEM (deg.) MDC (deg.) ICC3,1 (95% CI) SEM (deg.) MDC (deg.)
Shoulder flexion 0.97 (0.96–0.98) 1 2.7 0.98 (0.98–0.99) 0.74 2
Shoulder abduction 0.95 (0.92–0.97) 1.6 4.4 0.99 (0.98–0.99) 0.75 2.1
Shoulder ER 0.98 (0.97–0.99) 0.92 2.6 0.99 (0.98–0.99) 0.61 1.7
Shoulder IR 0.96 (0.94–0.98) 1.2 3.3 0.99 (0.98–0.99) 0.77 2.1
CI, confidence interval; ER, external rotation; ICC, intraclass correlation coefficient; IR, internal rotation; MDC, minimal detectable change;
SEM, standard error of measurement.

active shoulder mobility measurements using a digital compared with smartphones, as it has SEMs less
inclinometer and goniometer. Intrarater analysis than 2°.
suggested excellent reliability for all measurements
with both instruments with ICC values ranging from As expected, intrarater reliability values were higher
0.94 to 0.98. In the aforementioned study, the SEM than inter-rater values, which had less variability when
was 2°, whereas in the current study the SEM was the same rater was used. In addition, the values of the
less than 1°, and the MDC95 was lower to 2°, SEM and the MDC95 for intrarater reliability were
indicating superior reliability of the Kinovea smaller than that for inter-rater reliability, which is in
software. accordance with less measurement variation that is
typical when the same rater is used. It is worth
In comparison with more advanced measurement tools, mentioning that measurement variation of any
Kinovea software showed higher intratester reliability measurements or measurement tools, in general, is
compared with smartphone applications. Mitchell et al. more likely to be detected than no variation because
[33] examined the reliability of inclinometry-based the nature of reality is such that measurements are
and photo-based smartphone applications in the rarely perfectly reliable. This is due to multifactorial
measurement of active shoulder ER as compared sources to variation existing within the total
with standard goniometry (SG). Intrarater reliability measurement system [35].
using novice raters ranged from ICC values of 0.79 to
0.81 for the two applications and 0.82 with an SG Measurement variations found in the present study
value. Inter-rater reliability (novice/expert) for the two could be attributed to the following factors. First, there
applications ranged from ICC values of 0.92 to 0.94 is the human factor; the inter-rater variation could be
with an SG value at 0.91. Both applications were found higher than the intrarater variation because the analyses
to be reliable and comparable to SG. A photo-based were made by three different raters with different
application potentially offers a superior method of personal characteristics and years of experience.
measurement, as visualizing the landmarks may be Second, there is the time factor, as the variability
simplified in this format. In addition, it provides a within same day measurements could be due to the
record of measurement that is in agreement with the fact that the measurements were taken on two different
advantages of Kinovea software. occasions. Although these potential sources of error
existed, Kinovea software shows excellent reliability
Furthermore, in a study by Werner et al. [34] the and is believed to be a valuable clinical tool.
average ICC for the SG was 0.69; the average ICC
for the smartphone clinometer was 0.80. These values Kinovea software for shoulder ROM presents several
are lower than the values recorded by Kinovea in the advantages over currently used methods, including
current study. In addition, abduction had the lowest visual estimation, classic double-armed goniometer,
ICC values across examiners, and ER at 0° and 90° had digital inclinometry, and high-speed cinematography.
the highest ICC values, which are in agreement with The free, open-access software is widely available
the current findings. In the aforementioned study, to users, giving it a distinct advantage over other
SEM calculations for each measurement modality digital inclinometers and more complex measurement
were used to determine absolute reliability. The tools.
average clinometer had the lowest (best) SEM at
3.6°. In general, ER and IR measurements had the Strengths of the present study are highlighted as
highest SEMs, whereas abduction and forward flexion follows. First, the three raters were trained with
typically had the lowest SEMs. Their findings Kinovea software before the study, which could have
highlighted that Kinovea yields better reliability enhanced consistency in the measurement process.
86 Bulletin of Faculty of Physical Therapy, Vol. 21 No. 2, July-December 2016

Second, standardization of the procedures also could range of motion in patients with shoulder pain using a digital inclinometer.
BMC Musculoskelet Disord 2004; 5:18.
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