Sports Medicine Research: In the Lab & In the Field: Is the Scapula the Root of All Evil? (Sports Med Res)
Tuesday, November 19, 2013

Is the Scapula the Root of All Evil?

Is there a relationship between subacromial impingement syndrome and scapular orientation? A systematic review

Ratcliffe E, Pickering S, McLean S, Lewis J. Br J Sports Med. 2013 Oct 30. [Epub ahead of print]

Take Home Message: Currently, there is insufficient evidence to demonstrate that consistent patterns of scapular dyskinesis in patients with SIS exist. Rehabilitation of the scapula in patients with SIS is currently not supported by the literature.

Altered scapular orientation, termed scapular dyskinesis, is often found in conjunction with subacromial impingement syndrome (SIS).  SIS is defined as shoulder pain and pathology within the subacromial space, but its etiology is not fully understood. Non-surgical treatment options often focus on restoration of normal scapular posture; however, it is unclear whether altered scapular orientation contributes to or instead compensates for this syndrome.  Identification of common patterns in scapular orientation could guide treatment options for patients with SIS.  Therefore, the purpose of this study was to systematically review the literature to examine whether a difference exists in scapular orientation between people without shoulder symptoms and those with SIS.  The authors performed a systematic review of the literature.  Of the 7445 papers identified, 18 were selected for further analysis.  Two-independent reviewers assessed these studies for inclusion, data extraction and quality.  Only 10 studies met the inclusionary criteria.  In each of the studies, participants were recruited from numerous populations (clinics, sports teams, construction industries, and wheelchair users) and wide age ranges (17-74 years), and pain was assessed using various pain scores.  Additionally, various methods were utilized to assess scapular orientation including 2D radiological measurements, 360 degree inclinometers and 3D motion and tracking devices.  Findings from each study were inconsistent.  Specifically, some studies reported patterns of reduced upward rotation, increased anterior tilting and medial rotation while others reported the opposite or no differences when compared to asymptomatic controls.

The authors of this study sought to identify relationships between SIS and scapular orientation; however, results of their systematic review demonstrated a lack of consistency in the methodology and results.  Alterations in scapular orientation were observed in many patients with SIS; however, results were often contradictory and therefore patterns could not be identified.  It is possible that differences in scapular orientation may be confounded by the multi-factorial nature of SIS.  Specifically, it is possible that the increased scapular upward rotation and posterior tilting observed in some patients with SIS may be explained as a compensatory strategy to reduce pain while other patients may be unable to compensate.  Additionally, it is possible that the contradictory result of decreased scapular upward rotation and increased anterior tilting observed in some patients may be the cause of the SIS, reducing subacromial space and resulting in mechanical abrasion of the subacromial tissues.  In conclusion, findings from this systematic review suggest that no definitive relationship exists between scapular orientation and SIS.  The authors state that rehabilitation of the scapula to restore “normal” scapular posture is currently not supported by the literature.  Further research is necessary in order to establish a common pattern in scapular orientation in patients with SIS, using standardized methodology and within appropriate populations, in order to guide management of this syndrome. 

Questions for Discussion: Do you think that altered scapular orientation contributes to or instead compensates for SIS? Do your patients with SIS benefit from rehabilitation of the scapula?

Written by: Katie Reuther
Reviewed by:  Stephen Thomas

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Ratcliffe E, Pickering S, McLean S, & Lewis J (2013). Is there a relationship between subacromial impingement syndrome and scapular orientation? A systematic review. British Journal of Sports Medicine PMID: 24174615

7 comments:

Mark Shires, ATC said...

I think there is a disconnect in the research in understanding the resting measure of upward rotated i.e. position 1 of LSST and the lack of upward rotation with motion.
The lack of function of the lower trap and serratus anterior will create an un-teathered scapula that tips forward and protracts.

Katie Reuther said...

Thanks for your comment. I agree with your statement. Many of the inconsistencies that are present in the literature may be related to differences in static positioning vs. dynamic positioning of the scapula. Static measurements do not capture alterations in neuromuscular control that may affect scapular orientation.

Jonathan Fass said...

Mark, I disagree here: even if this happens, this "untethering" of the scapula - which we do *not* have evidence for - we do not know if this is clinically relevant: as this research shows, it may be a compensation to something else, not a cause of issues down the line. The literature is fairly consistent in the *inconsistency* of mechanics as a cause of pain in our patients, and rather than assuming that the evidence is to blame, we need to consider that it is in fact the hypothesis being examined that demonstrates the "disconnect" to reality

Caitlyn Richbourg said...

I agree that scapular dyskinesis and SIS is kind of the battle between which came first, chicken or the egg concept. However, I think proper evaluation of scapular positioning and movement patterns is often over looked and under appreciated. I believe that the scapula could have an effect on SIS symptoms, and if it is not the actual cause of the pathology, treating proper scapular mechanics may help alleviate some of the symptoms and/or prevent further issues. SIS specifically is treated conservatively, so what would be the harm in adding more scapular stabilizer strengthening, and kinesis patterns into rehab? I would argue that a good handful of SIS patients experience a lot of their symptoms from poor scapular control and the scapula should always be addressed with any type of shoulder pathology, especially SIS.

Katie Reuther said...

Thanks for your comment. It is very likely that rehabilitation of the scapula is helpful in patients with SIS and abnormal scapular positioning. However, the current evidence does not support this. I think this article demonstrates the need for more research in this area to demonstrate the importance of scapular positioning and particularly to identify the cause or effect relationships between abnormal scapular positioning and SIS (which is still unknown).

Bethany Rohl said...

While the goal of athletic training is to utilize evidence based practice, if the current available research does not provide adequate conclusions, then clinicians need to utilize their best judgement. The results of the systematic review did not have conclusive results regarding whether or not the scapula and SIS are related. I agree with Caitlyn that many SIS patients have poor scapular control. Until there is evident to support that there is not a benefit to doing scapular exercises in SIS patients, it is best practice to continue.

Katie Reuther said...

Great point! Although this study did not find common patterns of abnormal scapular movements in patients with SIS, scapular exercises will still likely benefit these patients.

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