BY COLIN PATER50N.
MCSP
INTRODUCTION
N umerous treatment options are
available for the treatment of shoulder
impingement Donatelli (1) discusses the use
of manual therapy, myofascial treatment,
graduated exercise and strengthening
programmes. However taping has become
a popular adjunct to physiotherapy practice,
popularised by McConnell (2,3). Due to this
popularity there has been a steady growth
in published research, but it must be noted
that the majority concentrate on the effects
on lower limb pathologies. Clinically the use
of taping is usually combined with a specific
exercise programme. However this article will
concentrate solely on the use of taping for
shoulder impingement, its effect on scapula
muscle activity and its efficacy
According to Kamkar, Irrgang and Whitney
(4) shoulder impingement refers to the signs
and symptoms of pain and dysfunction,
which are a consequence of pathology
that either decreases the volume of the
subacromial space or increases the size of
its contents. Bigliani et al (5) categorised
impingement into two groups: primary and
14
Shoulder impingement is a common dysfunction presenting
to therapists clinically. Altered scapula movement, or scapula
dyskinesia, is now regularly implicated as a contributing factor
to shoulder impingement due to growing research evidence
highlighting alterations in muscle activity of the scapula rotators.
Numerous treatment options for scapula dyskinesia are
available including exercise therapy postural awareness and
taping. The use of taping techniques to improve the activity of
muscles around the shoulder girdle has in recent years grown
in popularity With the growing need for research evidence to
support clinical practice, this paper provides a review of the
current evidence on both scapular muscle activity in subjects
with impingement. The second paper reviews the use of taping
techniques to alter muscle activity around the scapula.
secondary impingement. They defined primary dyskinesia and posture (6-8) and are
impingement as an outlet stenosis of the considered to be associated with altered
subacromial space due to anatomical factors motor recruitment and are common in over-
such as a hooked acromion. Secondary head athletes (8).
impingement was considered to be due to
physiological factors. These factors could SCAPULA STABILITY
inciude glenohumeral instability, scapulothoracic Scapula mechanics, which research has
sportEX medicine 2008:36(Apr):14-17

highlighted as a main cause of dysfunction in
the shoulder, are now commonly assessed in
patients with impingement (9,10}. Ellenbecker
(11), Mottram (9) and Host (12) recognise
the inability to control the movement of
the scapula during upper limb movements
and note this frequently accompanies the
development of shoulder pain.
The scapula has numerous functions
contributing to both stability and mobility of
the shoulder complex. It provides a base
for muscle attachment and its appropriate
orientation optimises the length tension
relationships of these muscles (9). Kibler (8)
commented that when the scapula loses
its stability, the orientation of the glenoid
fossa is compromised, preventing optimum
function of both the glenohumeraf joint and
supporting musculature, namely the rotator
cuff. Coordinated scapula movement is
therefore essential and force couples exist
to produce this smooth movement. It is when
these force couples become dysfunctional
that problems are thought to arise (13), The
pnmary scapula force couple associated
with shoulder elevation is between serratus
anterior and trapezius; resulting in lateral
rotation of the scapula (10). In the early range
of elevation both the upper fibres of trapezius
and serratus anterior are active. Later in range,
when the axis of rotation moves towards the
acromioclavicular joint, the lower fibres of
trapezius and serratus anterior are dominant
(114,15).
MOTOR CONTROL
DYSFUNCTION
It is commonly accepted that many factors
influence movement of the human body
including soft tissues, bone, joints and also the
nervous system. It is the nervous system that
controls the coordination of muscle activity
that allows effective and efficient movement
patterns to occur (16). A reduction in this
control of motor activity can contribute to pain
and dysfunction. Alternatively it is proposed
that pain and dyslunction can cause an
alteration in motor control.
Changes in sensory feedback, abnormal
reflex activation and reduced coordination
have all been identified as contributing to
deficits in the sensory control of movement
(16). The basis of closed-loop motor control
IS accurate sensory feedback to the central
nervous system (CNS). A reduced ability to
detect movement and a reduced repositioning
sense have occurred in populations with
musculoskeletal dysfunction; for example
subjects with tow back pain (LBP) (17), post
ankle sprain (18), subjects with shoulder
instability (}9) and subjects with osteoarthritis
of the knee (20). Reduced sensory input to
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REHABILITATION SHOULDER IMPINGEMENT
AN OVERALL IMBALANCE IN MUSCLE
ACTIVITY BETWEEN TRAPEZIUS AND
SERRATUS ANTERIOR CAN AFFECT THE
SCAPULA FORCE COUPLE AND RESULT IN
DYSFUNCTION AND PAIN
the CNS can lead to delayed reflex responses,
impaired coordination of voluntary movements
and faulty movement error detection and
correction (15). In addition any change in
muscle activity affects the sensation of
movement, Therefore factors such as fatigue,
antalgic movement patterns and pain-induced
muscle inhibition could all result in altered
motor control strategies that could potentially
exacerbate the initial dysfunction. Hence a
negative cycle is continually being reinforced
(16).
Dysfunction of the scapula stabilisers
has been highlighted clinically in subjects
with impingement (9). This is consistent
with studies in other anatomical regions that
demonstrate stability muscie dysfunction
associated with pain (16,21,22). Increased
anterior gienohumerai laxity has been
associated with poor scapula stability (4,23)-
Glenohumeral instability has also been
associated with reduced firing of the rotator
cuff (24), amplifying the joint instability further.
The scapula stabilising muscles have been
studied in both normal and painful shoulders
to determine alterations in firing patterns with
pain. An EMG study of !5 throwing athletes
by Glousman et al (24) observed reduced
serratus anterior activity in the group with
unstable shoulders, although caution should
be applied in extrapolating this data to
Figure t Right scapular winging
impingement patients, despite instability being
a potential cause of secondary impingement
(5).
Ludewig and Cook (25) investigated the
scapular muscle activity of 52 impingement
diagnosed subjects. Their results support
those of Glousman et al (24) by demonstrating
statistically significant alterations in scapula
muscle activation in impingement subjects.
Ludewig and Cook (25) also measured
the resulting effect on scapula positioning.
The impingement subjects demonstrated a
statistically significant reduction in serratus
anterior activity with a resulting reduction in
posterior tipping of the acromion and initial
upward rotation of the scapula, accentuating
the risk of subacromial impingement Increased
activity in both the upper and lower portions of
trapezius also reached statistical significance
from mid-range elevation upwards. However
the reliability of using skin markers for
kinematic analysis of true scapula positioning
was not discussed in the above studies.
Studies by Cools et al (26-28) have
also found altered scapular muscle activity
in impingement populations. Cools et al
(27) found overhead athletes with shoulder
pathology to exhibit decreased force output
of serratus anterior, resulting in an altered
muscle balance between serratus anterior
and trapezius. In the same study they
15
demonstrated reduced muscle activity in
lower trapezius during an isokinetic retraction
movement Cools et al (26) demonstrated
disordered timing of trapezius muscle activity
with significant delays in lower trapezius in
response to a sudden perturbation. Most
recently, Cools et al (28) demonstrated
increased muscle activity in upper trapezius
during both isokinetic shoulder abduction and
external rotation, and reduced activity in both
lower trapezius during abduction and middle
trapezius during external rotation, !t could be
argued there are conflicting results between
Cools et al (26-28) with earlier results of
Ludewig and Cook (25). However, all the
studies highlighted that an overall imbalance
in muscle activity between trapezius and
serratus anterior often attributes to muscles
compensating for altered activity within the
scapula force couple.
Two studies on swimmers compahng
subjects with and without impingement pain
observed delayed serratus anterior activity
(29) and reduced serratus anterior activity
(30) during elevation and during stroke
production respectively in the impingement
group No significant differences were found
between the two groups in the lovwer and
upper fibres of trapezius in either study
However clinical studies in non-athletes are
needed to allow generalisation of these
proposed altered temporal recruitment
patterns to normal functional activities.
Evidence exists that scapular dyskinesia
occurs in subjects with impingement, A study
by Warner et al (19) demonstrated increased
scapula winging, a pattern of scapula internal
rotation and anterior tipping. Studies by
Lukasiewicz et al (31) and Ludewig and Cook
(25) have demonstrated decreased posterior
tipping ol the scapular and scapular lateral
rotation during glenohumeral elevation. A
radiographic study by Endo et al (32) revealed
a decrease in lateral rotation of the scapula at
90" of glenohumeral elevation and posterior
tipping at both 90° and 45° elevation.
These findings appear consistent with the
EMG studies indicating a reduced activity of
serratus anterior which would result in both
reduced lateral rotation and posterior tipping of
the scapula.
Asymmetry of scapula elevation (31) and
reduced consistency of muscle activation
(29) have been demonstrated bilaterally in
impingement subjects with unilateral pain. Both
studies suggested a possible central motor
control issue could be at fault.
The above studies all presume that there
is one typical pattern of motor dysfunction
associated with shoulder impingement.
However Sahrmann (14) describes numerous
types of movement impairments which she
experiences clinically, the more common
examples are; scapula downward rotation
syndrome, scapular winging (figure 1) and
scapular abduction syndrome. She proposes
different underlying muscle length and
strength imbalances for each. Therefore, when
investigating shoulder impingement, subjects
might need to be subdivided into more specific
populations to gain clinically and statistically
significant results.
It is clear further studies are still needed
to build on the above studies but must
incorporate larger sample sizes, specific
pathology populations allowing clear clinical
applications and functional movement pattems
which are not necessarily sporting.
References
1. Donatelli RA. Functional anatomy and mechanics.
Physical Therapy of the Shoulder: 3rd edition
Churchill Livingstone 1997 ISBN 0443075913
2. McConnell J. The McConnell approach to the
problem shoulder Course notes 1994

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16 sportEX medicine 2008:36(Apr):14-17


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stability dysfunction - contemporary developments.
Manual Therapy 200l;6(l]:l5-26
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Movement Impairment Syndromes, 1st Edition:
Mosby 2002. ISBN
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cervicogenic disorders: assessment and
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ISBN 0443071543
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effects of lumbar fatigue on the ability to sense a
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in subjects with multiple ankle sprains. Physical
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19 Warner J j p Michele LJ, Arslanian LE, Kennedy
J Kennedy R, Scapulothoracic motion in normal
shoulders and shoulders with glenohumeral instability
and impingement syndrome Clinical Orthopaedics
and Related Research I996;285:191-199
20, Garsden LR and Bullock-Saxton JE, Joint
THE AUTHOR
Colin Pater5on MSc PGCert (Ed) MCSP MSMA is a chartered physiotherapist
who is both a freelance physiotherapist specialising in musculoskeletal
and sports injuries for adults and paediatrics and a lecturer at
Bournemouth University. He currently works as the team leader for the acute
paediatric physiotherapy team at Poole General Hospital. He also works with the
British Paralympic Association, England Hockey and has worked as a headquarters
physiotherapist at the last commonwealth games for Team England and the last 2
World University Games for the Great Britain team.
www.sportEX net
REHABILITATION SHOULDER IMPINGEMENT
reposition sense in subjects with uni-lateral
osteoarthritis of the knee. Clinical Rehabilitation
1999;13:148-155
21. Hides J Richardson C, Jull G. Multifidus recovery
is not automatic following resolution of acute first
episode low back pain Spine 1996;58(n):1531-1541
22. Cowan SM, Hodges PW, Bennell KL Crossley
KM. Altered vastii recruitment when people
with patellofemoral pain syndrome complete a
Ask for a FREE demo CD
postural task Archives of Physical Medicine and
Rehabilitation 2002;83:969-995
and see how easy it is to
23 Jobe FW.Pfnk M Classification and treatment of create exercise handouts
shoulder dysfunction in the overhead athlete. Journal
of Orthopaedic and Sports Physical Therapy
1993;18(2):427-432 1. Select
24. Glousman R, Jobe F, Tibone J, Moynes D, Use the sorting
Antonelli D, Perry J Dynamic electromyographic
system to
quickly find
analysis of the throwing shoulder with glenohumeral
the exercises
instability. The Journal of Bone and Joint Surgery you require
1988;70(2):220-226
25 Ludewig PM, Cook TM. Alterations in shoulder
kinematics and associated muscle activity in people
with symptoms of shoulder impingement. Physical
2. Edit
Therapy 2000,80(3):276-291
Personalise
your handout
26 Cools AM, Witvrouw EE, Dedercq GA, Daneels L,
by editing
Cambier DC. Scapular muscle recruitment pattems: the text
trapezius muscle latency in overhead athletes with
and without impingement symptoms. American
Journal of Sports Medicine 2003;31(4):542-549
27. Cools AM, Witvrouw EE, Dedercq GA,
3. Print
Vanderstraeten G, Cambier DC, Evaluation of
Print your
isokinetic force production and associated muscle
handout with
activity in tf>e scapuiar rotators during a protraction- clear pictures
retraction movement in overhead athletes with and detailed
impingement symptoms. British Journal of Sports instructions
Medicine 2004;38:64-68
28. Cools AM,Declercq GA. Cambier DC, Witvrouw
EE, Trapezius activity and intramuscular balance
dunng isokinetic exercise in overhead althetes with
Impingement symptoms Scandinavian Journal of
Medicine and Science in Sports 2007;17:25-33
29. Wadsworth DJ, Bullock-Saxton JE
Recmitment pattems of the scapular rotator
muscles in freestyle swimmers with subacromial
impingement Orthopaedics and Clinical Science
1997;18:618-624
30. Pink M, Jobe FW, Perry J Browne A, Scovazzo
Thera-Band
ML Kerrigan J. The painful shoulder during the
butterfly stroke Clinical Orthopaedics and Related Exercises
Research 1993;288:60-72 FREE download from
31. Lukasiewicz AC, McClure P Michener L Pratt N,
Sennett B. Comparison of 3-dimensional scapular
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position and onentation between subjects with
and without shoulder impingement. Journal of
Orthopaedic and Sports Physical Therapy Exercises available for
1999;29(10):574-586
32 Endo K, Ikata T Katoh S, Takeda Y. Radiographic Rehabilitation
assessment of scapular rotational tilt in chronic Fitness & Sports Therapy
shoulder impingement syndrome Journal of Information & Training
Orthopaedic Science 200l;6;3-10
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