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Is there a relationship between subacromial impingement syndrome and scapular orientation? A systematic review
  1. Elizabeth Ratcliffe1,
  2. Sharon Pickering2,
  3. Sionnadh McLean3,
  4. Jeremy Lewis4,5,6
  1. 1Department of Therapies, Chelsea & Westminster Hospital, London, UK
  2. 2Deakin University, Geelong, Victoria, Australia
  3. 3Department of Allied Health Professions, Sheffield Hallam University, Sheffield, UK
  4. 4Department of Allied Health Professions and Midwifery, University of Hertfordshire, Hertfordshire, UK
  5. 5Central London Community Healthcare NHS Trust, London, UK
  6. 6St George's NHS Healthcare Trust, London, UK
  1. Correspondence to Elizabeth Ratcliffe, Department of Therapies, Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK; lizratcliffe{at}


Background Alterations in scapular orientation and dynamic control, specifically involving increased anterior tilt and downward rotation, are considered to play a substantial role in contributing to a subacromial impingement syndrome (SIS). Non-surgical intervention aims at restoring normal scapular posture. The research evidence supporting this practice is equivocal.

Objective The aim of this study was to systematically review the relevant literature to examine whether a difference exists in scapular orientation between people without shoulder symptoms and those with SIS.

Data sources MEDLINE, AMED, EMBASE, CINAHL, PEDro and SPORTDiscus databases were searched using relevant search terms up to August 2013. Additional studies were identified by hand-searching the reference lists of pertinent articles.

Review methods Of the 7445 abstracts identified, 18 were selected for further analysis. Two reviewers independently assessed the studies for inclusion, data extraction and quality, using a modified Downs and Black quality assessment tool.

Results 10 trials were included in the review. Scapular position was determined through two-dimensional radiological measurements, 360° inclinometers and three-dimensional motion and tracking devices. The findings were inconsistent. Some studies reported patterns of reduced upward rotation, increased anterior tilting and medial rotation of the scapula. In contrast, others reported the opposite, and some identified no difference in motion when compared to asymptomatic controls.

Conclusions The underlying aetiology of SIS is still debated. The results of this review demonstrated a lack of consistency of study methodologies and results. Currently, there is insufficient evidence to support a clinical belief that the scapula adopts a common and consistent posture in SIS. This may reflect the complex, multifactorial nature of the syndrome. Additionally, it may be due to the methodological variations and shortfalls in the available research. It also raises the possibility that deviation from a ‘normal’ scapular position may not be contributory to SIS but part of normal variations. Further research is required to establish whether a common pattern exists in scapular kinematics in SIS patients or whether subgroups of patients with common patterns can be identified to guide management options. Non-surgical treatment involving rehabilitation of the scapula to an idealised normal posture is currently not supported by the available literature.

  • Shoulder injuries
  • Sports physiotherapy

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