By Nick Ng, BA, CMT
A recent study published in the Journal of Shoulder and Elbow Surgery challenges the existing idea that shoulder impingement syndrome (SIS) is caused by compression between the coracoacromial arch and the humerus during shoulder elevation above the shoulder height. Oftentimes, patients with SIS tend to have anteriorly tilted shoulders, causing the typical hunching posture. (1) Nine fresh cadavers were used where one scapula and one humerus — along with the rotator cuff muscles, subacromial bursa, and coracoacromial joint capsule — were amputated from the body and were mounted on a contraption that specifically measures a shoulder's range of motion within a given plane of motion.
After testing these shoulders by passively and dynamically moving them that mimic shoulder elevation, researchers from the Biomechanics Laboratory Division of Orthopedic Research and the Department of Orthopedic Surgery at the Mayo Clinic in Rochester, Minnesota, found that “anterior tilt of the scapula decreased subacromial contact pressure,” not increased as they had hypothesized. And so, scapular internal rotation did not affect pressure contact.
When they measured the amount of contact pressure as the scapula was elevated, the pressure “decrease linearly with anterior tilt,” and the difference between that and neutral scapular position was 20 degrees. Peak contact pressure did not change much during scapular internal rotation and downward rotation. Thus, this study — among several previous similar studies and reviews — does not support the belief that shoulders need to be “adjusted” to treat SIS since shoulder elevation and rounded shoulders do not necessarily cause painful symptoms.
When they measured the amount of contact pressure as the scapula was elevated, the pressure “decrease linearly with anterior tilt,” and the difference between that and neutral scapular position was 20 degrees. Peak contact pressure did not change much during scapular internal rotation and downward rotation. Thus, this study — among several previous similar studies and reviews — does not support the belief that shoulders need to be “adjusted” to treat SIS since shoulder elevation and rounded shoulders do not necessarily cause painful symptoms.
“[SIS] originally indicated jamming subacromial tissues between the acromion and humeral head, and thereby caused inflammation, pain, and tears in the rotator cuff. However, shoulder specialists including surgeons, therapists, and researchers have recently recognized that several factors are attributed to SIS,” Dr. Takayuki Muraki explained in an email interview with Massage & Fitness Magazine, who is an assistant professor at Tohoku University Graduate School of Medicine in the Department of Physical Medicine and Rehabilitation in Sendai, Japan. “In addition, SIS tends to be diagnosed inappropriately because pain in patients with SIS can come from several mechanisms other than subacromial impingement.”
The causes of SIS is multifactorial, not just one cause as some manual therapists and surgeons believe. “Several factors including glenohumeral joint position, capsule tightness, subacromial spur, rotator cuff dysfunction, and scapular position increase the subacromial contact pressure. These pathologic factors can lead to the damage on the rotator cuff and surrounding tissues, resulting in shoulder pain,” Muraki added. “However, an increase of subacromial contact pressure does not always provoke shoulder pain. In many cases, existence of inflamed tissue with low pain-threshold is necessary. Pain should be caused when contact pressure on the inflamed tissue increases in the subacromial space.”
Dr. Kai-Nan An, Professor Emeritus of the Mayo Clinic College of Medicine, who coauthored the research paper, emphasized that contact pressure does not always equate to pain unless the amount of pressure exceeds the patient's pain threshold.” Inflammation will reduce that threshold, so the likely of pain increased in inflamed tissue,” Dr. An mentioned. “On the other hand, the contact pressure along with gliding friction could cause micro-damage of the tissue or adaption and remodeling of the tissue, which ultimately leads to degeneration process.”
So what does this mean for manual therapists?
“Clinicians have believed that scapular posterior tilting lead to widening the subacromial space, then results in decrease of subacromial contact. This belief is one of the reasons why scapular posterior tilting is recommended to improve shoulder pain in patients with SIS who often show scapular anterior tilting during arm elevation,” Dr. Muraki explained. “However, our findings suggest that posterior tilting from anteriorly tilted position increase subacromial contact pressure and that exercise to tilt the scapular posteriorly is not recommended if subacromial contact pressure is causing pain.”
“The clinical significance of our finding is that anterior tilting may reduce the peak contact pressure. So it should be considered in the control of scapular motion in treating SIS,” Dr. An added.
The causes of SIS is multifactorial, not just one cause as some manual therapists and surgeons believe. “Several factors including glenohumeral joint position, capsule tightness, subacromial spur, rotator cuff dysfunction, and scapular position increase the subacromial contact pressure. These pathologic factors can lead to the damage on the rotator cuff and surrounding tissues, resulting in shoulder pain,” Muraki added. “However, an increase of subacromial contact pressure does not always provoke shoulder pain. In many cases, existence of inflamed tissue with low pain-threshold is necessary. Pain should be caused when contact pressure on the inflamed tissue increases in the subacromial space.”
Dr. Kai-Nan An, Professor Emeritus of the Mayo Clinic College of Medicine, who coauthored the research paper, emphasized that contact pressure does not always equate to pain unless the amount of pressure exceeds the patient's pain threshold.” Inflammation will reduce that threshold, so the likely of pain increased in inflamed tissue,” Dr. An mentioned. “On the other hand, the contact pressure along with gliding friction could cause micro-damage of the tissue or adaption and remodeling of the tissue, which ultimately leads to degeneration process.”
So what does this mean for manual therapists?
“Clinicians have believed that scapular posterior tilting lead to widening the subacromial space, then results in decrease of subacromial contact. This belief is one of the reasons why scapular posterior tilting is recommended to improve shoulder pain in patients with SIS who often show scapular anterior tilting during arm elevation,” Dr. Muraki explained. “However, our findings suggest that posterior tilting from anteriorly tilted position increase subacromial contact pressure and that exercise to tilt the scapular posteriorly is not recommended if subacromial contact pressure is causing pain.”
“The clinical significance of our finding is that anterior tilting may reduce the peak contact pressure. So it should be considered in the control of scapular motion in treating SIS,” Dr. An added.
Survey Says!
Like many studies, this one isn't without a few limitations. The authors mentioned that the scapular and humeral rotation in the study may likely be different in a living person. However, they cited a study by Ludewig et al. that demonstrated “in vivo glenohumeral joint was almost constant during thoracohumeral elevation in the scapular plane,” which is similar to what this study found. (2) Another limitation is that the cadaver study may not apply much to living patients with altered scapular motion.
While there are many factors that influence pain, this study — among many — stacks on top of others that indicate biomechanics factors alone do not cause pain. A recent systematic review published in Manual Therapy did not find a strong association between the curvature of the thoracic spine and shoulder pain, including SIS. (3) (We have covered this topic here.) An earlier systematic review published in the British Journal of Sports Medicine did not find a scapular position and movement to be reliable indicators of pain. Ratcliffe et al. stated, “deviation from a ‘normal’ scapular position may not be contributory to SIS but part of normal variations.” (4)
Like many studies, this one isn't without a few limitations. The authors mentioned that the scapular and humeral rotation in the study may likely be different in a living person. However, they cited a study by Ludewig et al. that demonstrated “in vivo glenohumeral joint was almost constant during thoracohumeral elevation in the scapular plane,” which is similar to what this study found. (2) Another limitation is that the cadaver study may not apply much to living patients with altered scapular motion.
While there are many factors that influence pain, this study — among many — stacks on top of others that indicate biomechanics factors alone do not cause pain. A recent systematic review published in Manual Therapy did not find a strong association between the curvature of the thoracic spine and shoulder pain, including SIS. (3) (We have covered this topic here.) An earlier systematic review published in the British Journal of Sports Medicine did not find a scapular position and movement to be reliable indicators of pain. Ratcliffe et al. stated, “deviation from a ‘normal’ scapular position may not be contributory to SIS but part of normal variations.” (4)
References
1. Muraki T, Yamamoto N, Sperling JW, Steinmann SP, Cofield RH, An KN. The effect of scapular position on subacromial contact behavior: a cadaver study. J Shoulder Elbow Surg. 2017 Jan 11. pii: S1058-2746(16)30540-7. doi: 10.1016/j.jse.2016.10.009.
2. Ludewig PM, Phadke V, Braman JP, Hassett DR, Cieminski CJ, LaPrade RF. Motion of the shoulder complex during multiplanar humeral elevation. J Bone Joint Surg Am. 2009;91:378-89.
3. Barrett E, O'Keeffe M, O'Sullivan K, Lewis J, McCreesh K. Is thoracic spine posture associated with shoulder pain, range of motion and function? A systematic review. Man Ther. 2016 Jul 21;26:38-46. doi: 10.1016/j.math.2016.07.008.
4. Ratcliffe E et al. Is there a relationship between subacromial impingement syndrome and scapular orientation? A systematic review. British Journal of Sports Medicine. 2014 Aug;48 (16):1251-6. doi:10.1136/bjsports-2013-092389.
1. Muraki T, Yamamoto N, Sperling JW, Steinmann SP, Cofield RH, An KN. The effect of scapular position on subacromial contact behavior: a cadaver study. J Shoulder Elbow Surg. 2017 Jan 11. pii: S1058-2746(16)30540-7. doi: 10.1016/j.jse.2016.10.009.
2. Ludewig PM, Phadke V, Braman JP, Hassett DR, Cieminski CJ, LaPrade RF. Motion of the shoulder complex during multiplanar humeral elevation. J Bone Joint Surg Am. 2009;91:378-89.
3. Barrett E, O'Keeffe M, O'Sullivan K, Lewis J, McCreesh K. Is thoracic spine posture associated with shoulder pain, range of motion and function? A systematic review. Man Ther. 2016 Jul 21;26:38-46. doi: 10.1016/j.math.2016.07.008.
4. Ratcliffe E et al. Is there a relationship between subacromial impingement syndrome and scapular orientation? A systematic review. British Journal of Sports Medicine. 2014 Aug;48 (16):1251-6. doi:10.1136/bjsports-2013-092389.
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