Is
there a relationship between subacromial impingement syndrome and scapular
orientation? A systematic review
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]
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.
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.
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.
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?
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
Related Posts:
2013 Consensus Statement From the ‘Scapular Summit’: Clinical Implications of Scapular Dyskinesis in Shoulder Injury
Wasted Effort or Useful Technique – What’s The Truth About Scapular Repositioning and Muscle Activation
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
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.
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.
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
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.
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).
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.
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.