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Journal of Shoulder and Elbow Surgery

Subacromial impingement syndrome: The role of posture and muscle imbalance

      Changes in upper body posture, colloquially termed forward head posture (FHP), are considered to be an etiologic factor in the pathogenesis of subacromial impingement syndrome (SIS). The literature suggests that postural deviations associated with FHP follow distinct patterns involving an increase in the thoracic kyphosis angle and a downwardly rotated, anteriorly tilted, and protracted scapula, which in turn leads to increased compression in the subacromial space. These postural changes are thought to occur concurrently with an imbalance of the musculature, and conservative rehabilitation commonly involves addressing both posture and muscle imbalance. There is a paucity of evidence supporting the hypothesis that posture and muscle imbalance are involved in the etiology of SIS. The purpose of this study was to investigate whether FHP was associated with an increased thoracic kyphosis, an altered position of the scapula; and a reduction in glenohumeral elevation range. Selected sagittal and frontal plane postural measurements were made in 60 asymptomatic subjects and 60 subjects with SIS. The findings suggested that upper body posture does not follow the set patterns described in the literature, and further research is required to determine whether upper body and scapular posture and muscle imbalance are involved in the pathogenesis of SIS.
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      Referencesl

        • Ayub E.
        Posture and the upper quarter.
        in: Donatelli R.A. Physical therapy of the shoulder. 2nd ed. Churchill Livingstone, Melbourne1991: 81-90
        • Basmajian J.V.
        • Bazant F.J.
        Factors preventing downward dislocation of the adducted shoulder joint.
        J Bone Joint Surg Am. 1959; 41: 1182-1186
        • Bigliani L.U.
        • Morrison D.S.
        • April E.W.
        The morphology of the acromion and its relationship to rotator cuff tears.
        Orthop Trans. 1986; 10: 228
        • Bland M.
        An introduction to medical statistics.
        3rd ed. Oxford University Press, Oxford2000
        • Budoff J.E.
        • Nirschl R.P.
        • Guidi J.
        Debridement of partial-thickness tears of the rotator cuff without acromioplasty.
        J Bone Joint Surg Am. 1998; 80: 733-748
        • Calliet R.
        Shoulder pain.
        3rd ed. FA Davis Company, Philadelphia1991
        • Campbell M.J.
        • Machin D.
        Medical statistics.
        2nd ed. John Wiley and Sons, New York1993
        • Chinn S.
        Repeatability and method comparison.
        Thorax. 1991; 46: 454-456
        • Chipchase L.S.
        • O’Connor D.A.
        • Costi J.J.
        • Krishnan J.
        Shoulder impingement syndrome.
        J Shoulder Elbow Surg. 2000; 9: 12-15
        • Conover W.J.
        Practical nonparametric statistics.
        3rd ed. John Wiley and Sons, New York1999
        • Crawford H.J.
        • Jull G.A.
        The influence of thoracic posture and movement on range of arm elevation.
        Physiother Theory Pract. 1993; 9: 143-148
        • Culham E.
        • Peat M.
        Spinal and shoulder complex posture. II: Thoracic alignment and shoulder complex position in normal and osteoporotic women.
        Clin Rehabil. 1994; 8: 27-35
        • DiVeta J.
        • Walker M.L.
        • Skibinski B.
        Relationship between performance of selected scapular muscles and scapular abduction in standing subjects.
        Phys Ther. 1990; 70: 470-476
        • Edelson J.
        • Teitz C.
        Internal impingement of the shoulder.
        J Shoulder Elbow Surg. 2000; 9: 308-315
        • Greenfield B.
        • Catlin P.A.
        • Coats P.W.
        • et al.
        Posture in patients with shoulder overuse injuries and healthy individuals.
        J Orthop Sports Phys Ther. 1995; 21: 287-295
        • Griegal-Morris P.
        • Larson K.
        • Mueller-Klaus K.
        • Oatis C.A.
        Incidence of common postural abnormalities in the cervical, shoulder and thoracic regions and their association with pain in two age groups of healthy subjects.
        Phys Ther. 1992; 72: 425-431
        • Grimmer K.
        An investigation of poor cervical resting posture.
        Aust J Physiother. 1997; 43: 7-16
        • Grimsby O.
        • Gray J.C.
        Interrelationship of the spine to the shoulder girdle.
        in: Donatelli R.A. Clinics in physical therapy physical therapy of the shoulder. 3rd ed. Churchill Livingstone, New York1997: 95-129
        • Hawkins R.J.
        • Kennedy J.C.
        Impingement syndrome in athletes.
        Am J Sports Med. 1980; 8: 151-158
        • Hawkins R.J.
        • Mohtadi N.G.H.
        Controversy in anterior shoulder instability.
        Clin Orthop. 1991; 272: 152-161
        • Jobe C.M.
        Superior glenoid impingement.
        Orthop Clin North Am. 1997; 28: 137-143
        • Jobe F.W.
        • Moynes D.R.
        Delineation of diagnostic criteria and a rehabilitation program for rotator cuff injuries.
        Am J Sports Med. 1982; 10: 336-339
        • Kebaetse M.
        • McClure P.
        • Pratt N.E.
        Thoracic position effect on shoulder range of motion, strength, and three-dimensional scapular kinematics.
        Arch Phys Med Rehabil. 1999; 80: 945-950
        • Kendall F.P.
        • McCreary E.K.
        • Provance P.G.
        Muscles testing and function.
        4th ed. Williams and Wilkins, Baltimore1993
        • Kessel L.
        • Watson M.
        The painful arc syndrome.
        J Bone Joint Surg Br. 1977; 59: 166-172
        • Kibler W.B.
        The role of the scapula in athletic shoulder function.
        Am J Sports Med. 1998; 26: 325-337
        • Lewis J.
        • Green A.
        • Yizhat Z.
        • Pennington D.
        Subacromial impingement syndrome.
        Physiotherapy. 2001; 87: 191-198
        • Ludewig P.M.
        • Cook T.M.
        Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement.
        Phys Ther. 2000; 80: 276-291
        • Lukasiewicz A.C.
        • McClure P.
        • Michener L.
        • Pratt N.
        • Sennett B.
        Comparison of 3-dimensional scapular position and orientation between subjects with and without shoulder impingement.
        J Orthop Sports Phys Ther. 1999; 29: 574-586
        • Matsen F.A.
        • Arntz C.T.
        Subacromial impingement.
        in: The shoulder. Volume 2. Saunders, Philadelphia1990: 623-646
        • Meister K.
        • Andrews J.
        Classification and treatment of rotator cuff injuries in the overhand athlete.
        J Orthop Sports Phys Ther. 1993; 18: 413-421
        • Morrison D.S.
        • Bigliani L.U.
        The clinical significance of variations in acromial morphology.
        Orthop Trans. 1987; 11: 234
        • Mottram S.L.
        Dynamic stability of the scapula.
        Man Ther. 1997; 2: 123-131
        • Nakajima T.
        • Rokuuma N.
        • Hamada K.
        • Tomatsu T.
        • Fukuda H.
        Histological and biomechanical characteristics of the supraspinatus tendon.
        J Shoulder Elbow Surg. 1994; 3: 79-87
        • Neer II, C.S.
        Anterior acromioplasty for the chronic impingement syndrome in the shoulder. A preliminary report.
        J Bone Joint Surg Am. 1972; 54: 41-50
        • Neer II, C.S.
        Impingement lesions.
        Clin Orthop. 1983; 173: 70-77
        • Neiers L.
        • Worrell T.W.
        Assessment of scapular position.
        J Sport Rehabil. 1993; 2: 20-25
        • O’Brien S.J.
        • Pagnani M.J.
        • Fealy S.
        • McGlynn S.R.
        • Wilson J.B.
        The active compression test.
        Am J Sports Med. 1998; 26: 610-613
        • O’Gorman H.J.
        • Jull G.A.
        Thoracic kyphosis and mobility.
        Physiother Theory Pract. 1987; 3: 154-162
        • Ozaki J.
        • Fujimoto S.
        • Nakagawa Y.
        • Masuhara K.
        • Tamai S.
        Tears of the rotator cuff of the shoulder associated with pathological changes in the acromion.
        J Bone Joint Surg Am. 1988; 70: 1224-1230
        • Portney L.G.
        • Watkins M.P.
        Foundations of clinical research.
        Appleton and Lange, Stanford (CT)1993
        • Prescher A.
        Anatomical basics, variations, and degenerative changes of the shoulder joint and shoulder girdle.
        Eur J Radiol. 2000; 35: 88-102
        • Raine S.
        • Twomey L.
        Posture of the head, shoulder and thoracic spine in comfortable erect standing.
        Aust J Physiother. 1994; 40: 25-32
        • Raine S.
        • Twomey L.T.
        Head and shoulder posture variations in 160 asymptomatic women and men.
        Arch Phys Med Rehabil. 1997; 78: 1215-1223
        • Randelli M.
        • Gambrioli P.L.
        Glenohumeral osteometry by computed tomography in normal and unstable shoulders.
        Clin Orthop. 1986; 208: 151-156
        • Saha A.K.
        Dynamic stability of the glenohumeral joint.
        Acta Orthop Scand. 1971; 42: 491-505
        • Sahrmann S.A.
        Diagnosis and treatment of movement impairment syndromes.
        Mosby, London2002
        • Sim J.
        • Wright C.
        Research in health care.
        Stanley Thomas Publishers Ltd, Cheltenham upon Tweed2000
        • Soslowsky L.
        • An C.
        • Johnston S.
        • Carpenter J.
        Geometric and mechanical properties of the coracoacromial ligament and their relationship to rotator cuff disease.
        Clin Orthop. 1994; 304: 10-17
      1. Testut L. Traité d’Anatomie Humaine (edition 7). Tome I: Osteologie, Arthrologie, Myologie, Paris, Doin; 1921. p. 503-4. In: Sarrafian SK. Gross and functional anatomy of the shoulder. Clin Orthop 1983;173:11-9.

      2. Testut L, Jacob O. Traité d’Anatomie Topographique avec Applications Medico-chirurgicales Tome 2, Paris, Doin; 1909. p. 687-8. In: Sarrafian SK. Gross and functional anatomy of the shoulder. Clin Orthop 1983;173:11-9.

        • Uhthoff H.K.
        • Sano H.
        Pathology of failure of the rotator cuff tendon.
        Orthop Clin North Am. 1997; 28: 31-41
        • Wang C.H.
        • McClure P.
        • Pratt N.E.
        • Nobilini R.
        Stretching and strengthening exercises.
        Arch Phys Med Rehabil. 1999; 80: 923-929
        • Warner J.J.P.
        • Micheli L.J.
        • Arslanian L.E.
        • Kennedy J.
        • Kennedy R.
        Patterns of flexibility, laxity and strength in normal shoulders and shoulders with instability and impingement.
        Am J Sports Med. 1990; 18: 366-375