Clinical Rheumatology

, Volume 32, Issue 1, pp 73–85 | Cite as

Scapular-focused treatment in patients with shoulder impingement syndrome: a randomized clinical trial

  • F. StruyfEmail author
  • J. Nijs
  • S. Mollekens
  • I. Jeurissen
  • S. Truijen
  • S. Mottram
  • R. Meeusen
Original Article


The purpose of this clinical trial is to compare the effectiveness of a scapular-focused treatment with a control therapy in patients with shoulder impingement syndrome. Therefore, a randomized clinical trial with a blinded assessor was used in 22 patients with shoulder impingement syndrome. The primary outcome measures included self-reported shoulder disability and pain. Next, patients were evaluated regarding scapular positioning and shoulder muscle strength. The scapular-focused treatment included stretching and scapular motor control training. The control therapy included stretching, muscle friction, and eccentric rotator cuff training. Main outcome measures were the shoulder disability questionnaire, diagnostic tests for shoulder impingement syndrome, clinical tests for scapular positioning, shoulder pain (visual analog scale; VAS), and muscle strength. A large clinically important treatment effect in favor of scapular motor control training was found in self-reported disability (Cohen’s d = 0.93, p = 0.025), and a moderate to large clinically important improvement in pain during the Neer test, Hawkins test, and empty can test (Cohen’s d 0.76, 1.04, and 0.92, respectively). In addition, the experimental group demonstrated a moderate (Cohen’s d = 0.67) improvement in self-experienced pain at rest (VAS), whereas the control group did not change. The effects were maintained at three months follow-up.


Impingement Motor control Physical therapy Scapula Shoulder pain 



This study was financially supported by MSD Europe bvba, Nijverheidsstraat 18, Londerzeel, Belgium, and by research grant (G842) supplied by the Department of Health Sciences, Artesis University College Antwerp, Antwerp, Belgium. The material used in this study was provided by MSD Europe bvba.




  1. 1.
    Kessel L, Watson M (1977) Painful arc syndrome – clinical classification as a guide to management. J Bone Joint Surg 59:166–172Google Scholar
  2. 2.
    Lewis J, Green A, Wright C (2005) Subacromial impingement syndrome: the role of posture and muscle imbalance. J Should Elbow Surg 14:385–392CrossRefGoogle Scholar
  3. 3.
    Kulenkampff HA, Reichelt A (1989) Studies on conservative and operative treatment of the supraspinatus syndrome. Akt Rheum 14:70–76CrossRefGoogle Scholar
  4. 4.
    Koehler SM, Thorson DC (1996) Swimmer’s shoulder – targeting treatment. Phys Sportsmed 24:39–50PubMedGoogle Scholar
  5. 5.
    Wilk KE, Obna P, Simpson CD, Cain EL, Dugas J, Andrews JR (2009) Shoulder injuries in the overhead athlete. J Orthop Sports Phys 39:38–54Google Scholar
  6. 6.
    Viikari-Juntura E, Shiri R, Solovieva S, Karpinnen J, Leino-Arjas P, Varonen H, Kalso E, Ukkola O (2008) Risk factors of atherosclerosis and shoulder pain – Is there an association? A systemic Review. Eur J Pain 12:412–426PubMedCrossRefGoogle Scholar
  7. 7.
    Walker-Bone K, Palmer KT, Reading I, Coggon D, Cooper C (2004) Prevalence and impact of musculoskeletal disorders of the upper limb in the general population. Arthr Rheumathol 51:642–651CrossRefGoogle Scholar
  8. 8.
    Luime JJ, Koes BW, Hendriksen IJ, Burdorf A, Verhagen AP, Miedema HS et al (2004) Prevalence and incidence of shoulder pain in the general population: a systematic review. Scand J Rheumatol 33:73–81PubMedCrossRefGoogle Scholar
  9. 9.
    Neer CS II (1972) Anterior acromioplasty for the chronic impingement syndrome in the shoulder. A preliminary report. J Bone Joint Surg Am 54A:41–50Google Scholar
  10. 10.
    Walch G, Boileau P, Noel E et al (1992) Impingement of the deep surface of the supraspinatus tendon on the posterosuperior glenoid rim: an arthroscopic study. J Should Elbow Surg 1:238–245CrossRefGoogle Scholar
  11. 11.
    Cools AM, Cambier D, Witvrouw EE (2008) Screening the athlete’s shoulder for impingement symptoms: a clinical reasoning algorithm for early detection of shoulder pathology. Br J Sports Med 42:628–635PubMedCrossRefGoogle Scholar
  12. 12.
    Borsa PA, Timmons MK, Sauers EL (2003) Scapular-positioning patterns during humeral elevation in unimpaired shoulders. J Athl Train 38:12–17PubMedGoogle Scholar
  13. 13.
    Kibler BW, Sciascia A, Dome D (2006) Evaluation of apparent and absolute supraspinatus strength in patients with shoulder injury using the scapular retraction test. Am J Sports Med 34:1643–1647PubMedCrossRefGoogle Scholar
  14. 14.
    Burkhart S, Morgan C, Kibler W (2003) The disabled shoulder: spectrum of pathology part III: the SICK scapula, scapular dyskinesis, the kinetic chain, and rehabilitation. Arthroscopy 19:641–661PubMedCrossRefGoogle Scholar
  15. 15.
    McClure P, Tate A, Kareha S, Irwin D, Zlupko E (2009) A clinical method for identifying scapular dyskinesis, Part 1: reliability. J Athl Train 44:160–164PubMedCrossRefGoogle Scholar
  16. 16.
    Mottram S (1997) Dynamic stability of the scapula. Man Ther 2:123–131PubMedCrossRefGoogle Scholar
  17. 17.
    Blevins F (1997) Rotator cuff pathology in athletes. Sports Med 24:205–220PubMedCrossRefGoogle Scholar
  18. 18.
    Kaplan LD, McMahon PJ, Towers J et al (2004) Internal impingement: findings on magnetic resonance imaging and arthroscopic evaluation. Arthroscopy 20:701–704PubMedGoogle Scholar
  19. 19.
    Atalar H, Yilmaz C, Polat O, Selek H, Uras I, Yanik B (2009) Restricted scapular mobility during arm abduction: implications for impingement syndrome. Acta Orthop Belgica 75:19–24Google Scholar
  20. 20.
    Cools AM, Witvrouw EE, Declercq GA, Vanderstraeten GG, Cambier DC (2005) Evaluation of isokinetic force production and associated muscle activity in the scapular rotators during a protraction-retraction movement in overhead athletes with impingement symptoms. Br J Sports Med 38:64–68CrossRefGoogle Scholar
  21. 21.
    Endo K, Yukata K, Yasui N (2004) Influence of age on scapulo-thoracic orientation. Clin Biomech 19:1009–1013CrossRefGoogle Scholar
  22. 22.
    Hébert LJ, Moffet H, McFadyen BJ, Dionne CE (2002) Scapular behaviour shoulder impingement syndrome. Arch Phys Med Rehabil 83:60–69PubMedCrossRefGoogle Scholar
  23. 23.
    Host HH (1995) Scapular taping in the treatment of anterior shoulder impingement. Phys Ther 75:803–812PubMedGoogle Scholar
  24. 24.
    Lewis J, Green A, Reichard Z, Wright C (2002) Scapular position: the validity of skin surface palpation. Man Ther 7:26–30PubMedCrossRefGoogle Scholar
  25. 25.
    Ludewig PM, Cook TM (2000) Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement. Phys Ther 80:276–291PubMedGoogle Scholar
  26. 26.
    McClure PW, Michener LA, Karduna AR (2006) Shoulder function and 3-dimensional scapular kinematics in people with and without shoulder impingement syndrome. Phys Ther 86:1075–1090PubMedGoogle Scholar
  27. 27.
    Schmitt L, Snyder-Mackler L (1999) Role of scapular stabilizers in etiology and treatment of impingement syndrome. J Orthop Sports Phys Ther 29:31–38PubMedGoogle Scholar
  28. 28.
    Lukasiewicz AC, McClure P, Michener L, Pratt N, Sennet B (1999) Comparison of 3-dimensional scapular position and orientation between subjects with and without shoulder impingement. J Orthop Sports Phys Ther 29:574–586PubMedGoogle Scholar
  29. 29.
    Morrissey D, Morrissey MC, Driver W, King JB, Woledge RC (2008) Manual landmark identification and tracking during the medial rotation test of the shoulder: an accuracy study using three-dimensional ultrasound and motion analysis measures. Man Ther 13:529–535PubMedCrossRefGoogle Scholar
  30. 30.
    Smith M, Sparkes V, Busse M, Enright S (2009) Upper and lower trapezius muscle activity in subjects with subacromial impingement symptoms: Is there imbalance and can taping change it? Phys Ther Sport 10:45–50PubMedCrossRefGoogle Scholar
  31. 31.
    Borstad JD, Ludewig PM (2005) The effect of long versus short pectoralis minor resting length on scapular kinematics in healthy individuals. J Orthop Sports Phys Ther 35:227–238PubMedGoogle Scholar
  32. 32.
    Roy JS, Moffet H, Hébert L, Lirette R (2009) Effect of motor control and strengthening exercises on shoulder function in persons with impingement syndrome: A single-subject study design. Man Ther 14:180–188PubMedCrossRefGoogle Scholar
  33. 33.
    Bernhardsson S, Klintberg IH, Wendt GK (2011) Evaluation of an exercise concept focusing on eccentric strength training of the rotator cuff for patients with subacromial impingement syndrome. Clin Rehab 25:69–78CrossRefGoogle Scholar
  34. 34.
    Kuhn JE (2009) Exercise in the treatment of rotator cuff impingement: A systematic review and a synthesized evidence-based rehabilitation protocol. J Should Elbow Surg 18:138–160CrossRefGoogle Scholar
  35. 35.
    Green S, Buchbinder R, Glazier R, Forbes A (1998) Systematic review of randomised controlled trials of interventions for painful shoulder: selection criteria, outcome assessment, and efficacy. BMJ 316:354–360PubMedCrossRefGoogle Scholar
  36. 36.
    Desmeules F, Cote CH, Fremont P (2003) Therapeutic exercise and orthopedic manual therapy for impingement syndrome: a systematic review. Clin J Sport Med 13:176–182PubMedCrossRefGoogle Scholar
  37. 37.
    Faber E, Kuiper JI, Burdorf A, Miedema HS, Verhaar JA (2006) Treatment of impingement syndrome: a systematic review of the effects on functional limitations and return to work. J Occup Rehab 16:7–25CrossRefGoogle Scholar
  38. 38.
    Kromer TO, Tautenhahn UG, de Bie RA, Staal JB, Bastiaenen CHG (2009) Effects of Physiotherapy in patients with shoulder impingement syndrome: a systematic review of the literature. J Rehab Med 41:870–888CrossRefGoogle Scholar
  39. 39.
    Van der Windt DAWM, van der Heijden GJMJ, de Winter AF et al (1998) The responsiveness of the Shoulder Disability Questionnaire Annals of the Rheumatic Diseases. Ann Rheum Dis 57:82–87PubMedCrossRefGoogle Scholar
  40. 40.
    Dorrestijn O, Stevens M, Diercks RL, van der Meer K, Winters JC (2007) A new interdisciplinary treatment strategy versus usual medical care for the treatment of subacromial impingement syndrome: a randomized controlled trial. BMC Musculoskelet Disord. doi: 10.1186/1471-2474-8-15
  41. 41.
    Gürsel YK, Ulus GY, Bilgiç A, Dinçer G, van der Heijden GJMG (2004) Adding ultrasound in the management of soft tissue disorders of the shoulder: a randomized placebo-controlled. Trial Phys Ther 84:336–343Google Scholar
  42. 42.
    van Wilgen CP, Dijkstra PU, van der Laan BFAM, Plukker JTM, Roodenburg JLN (2004) Shoulder complaints after nerve sparing neck dissections. Int J Oral Maxillofac Surg 33:253–257PubMedCrossRefGoogle Scholar
  43. 43.
    Van der Heijden GJMG, Leffers P, Bouter LM (2000) Shoulder disability suestionnaire design and responsiveness of a functional status measure. J Clin Epidem 53:29–38CrossRefGoogle Scholar
  44. 44.
    Paul A, Lewis M, Shadforth MF et al (2004) A comparison of four shoulder-specific questionnaires in primary care. Ann Rheum Dis 63:1293–1299PubMedCrossRefGoogle Scholar
  45. 45.
    Smidt N, van der Windt DA, Assendelft WJ, Mourits AJ, Devillé WL, De Winter AF, Bouter LM (2002) Interobserver reproducibility of the assessment of severity of complaints, grip strength, and pressure pain threshold in patients with lateral epicondylitis. Arch Phys Med Rehabil 83:1145–1150PubMedCrossRefGoogle Scholar
  46. 46.
    Bijur PE, Latimer CT, Gallagher EJ (2002) Validation of a verbally administered numerical rating scale of acute pain for use in the emergency department. Academ Emerg Med 10:390–392CrossRefGoogle Scholar
  47. 47.
    Jensen MP, Karoly P, Braver S (1986) The measurement of clinical pain intensity: a comparison of six methods. Pain 27:117–126PubMedCrossRefGoogle Scholar
  48. 48.
    Mark HSM, Au TTS, Choi YF, Wong TW (2009) The minimum clinically significant difference in visual analogue scale pain score in a local emergency setting. Hong Kong J Emerg Med 16:233–236Google Scholar
  49. 49.
    Struyf F, Nijs J, De Coninck K, Giunta M, Mottram S, Meeusen R (2009) Clinical assessment of scapular positioning in musicians: an inter-tester reliability study. J Athl Train 44:519–526PubMedCrossRefGoogle Scholar
  50. 50.
    Nijs J, Roussel N, Vermuelen K, Souvereyns G (2005) Scapular positioning in patients with shoulder pain: a study examining the reliability and clinical importance of 3 clinical tests. Arch Phys Med Rehab 86:1349–1355CrossRefGoogle Scholar
  51. 51.
    Lewis JS, Valentine RE (2007) The pectoralis minor length test: a study of the intra-rater reliability and diagnostic accuracy in subjects with and without shoulder symptoms. BMC Musc Skel Dis 8:63. doi: 10.1186/1471-2474-8-64 CrossRefGoogle Scholar
  52. 52.
    Watson L, Balster SM, Finch C et al (2005) Measurement of scapula upward rotation: a reliable clinical procedure. Br J Sports Med 39:599–603PubMedCrossRefGoogle Scholar
  53. 53.
    Holtermann A, Roeleveld K, Mork PJ, Grönlund C, Karlsson JS, Andersen LL, Olsen HB, Zebis MK, Sjøgaard G, Søgaard K (2009) Selective activation of neuromuscular compartments within the human trapezius muscle. J Electromyogr Kinesiol 19:896–902PubMedCrossRefGoogle Scholar
  54. 54.
    Cools A, Declercq G, Cambier D, Mahieu N, Witvrouw E (2007) Trapezius activity and intramuscular balance during isokinetic exercise in overhead athletes with impingement symptoms. Scand J Med Sci Sports 17:25–33PubMedGoogle Scholar
  55. 55.
    Jonsson P, Wahlström P, Obergh L, Alfredson H (2006) Eccentric training in chronic painful impingement syndrome of the shoulder: results of a pilot study. Knee Surg Sports Traumatol Arthrosc 14:76–81PubMedCrossRefGoogle Scholar
  56. 56.
    Cohen J (1988) Statistical power analysis for the behavioral sciences Series. Editor, Hillsdale, New Jersey, Lawrence Erlbaum AssociatesGoogle Scholar
  57. 57.
    Lombardi I, Magri AG, Fleury AM, Da Silva AC, Natour J (2008) Progressive resistance training in patients with shoulder impingement syndrome: a randomized controlled trial. Arthritis Rheum 59:615–622PubMedCrossRefGoogle Scholar
  58. 58.
    Juul-Kristensen B, Hilt K, Enoch F, Remvig L, Sjogaard G (2011) Scapular dyskinesis in trapezius myalgia and intraexaminer reproducibility of clinical tests. Physiother Theory Pract 27:492–502PubMedCrossRefGoogle Scholar
  59. 59.
    Smith J, Dietrich CT, Kotajarvi BR, Kaufman KR (2006) The effect of scapular protraction on isometric shoulder rotation strength in normal subjects. J Should Elbow Surg 15:339–343CrossRefGoogle Scholar
  60. 60.
    Hayes K, Walton JR, Szomor ZL, Murrell GA (2002) Reliability of 3 methods for assessing shoulder strength. J Should Elbow Surg 11:33–39CrossRefGoogle Scholar

Copyright information

© Clinical Rheumatology 2012

Authors and Affiliations

  • F. Struyf
    • 1
    • 2
    • 6
    Email author
  • J. Nijs
    • 1
    • 2
    • 3
  • S. Mollekens
    • 1
  • I. Jeurissen
    • 4
  • S. Truijen
    • 1
  • S. Mottram
    • 5
  • R. Meeusen
    • 2
  1. 1.Division of Musculoskeletal Physiotherapy, Department of Health SciencesArtesis University College AntwerpAntwerpBelgium
  2. 2.Department of Human Physiology, Faculty of Physical Education and PhysiotherapyVrije Universiteit BrusselBrusselsBelgium
  3. 3.Department of rehabilitation and physiotherapyUniversity Hospital BrusselsBrusselsBelgium
  4. 4.Private Medical Practice De BermPaalBelgium
  5. 5.KC InternationalChichesterUK
  6. 6.Campus HIKE, Departmentt GArtesis University College AntwerpMerksemBelgium

Personalised recommendations