Journal of Back and Musculoskeletal Rehabilitation 26 (2013) 227242 227

DOI 10.3233/BMR-130373
IOS Press

Case Report

Functional thoracic hyperkyphosis model for

chronic subacromial impingement syndrome:
An insight on evidence based Treat the
Cause concept A case study and literature
review
M. Nagarajana, and P. Vijayakumarb
a
Faculty of Health and Life Sciences, INTI International University, Laureate International Universities, Nilai,
Malaysia
b
Faculty of Allied Health Sciences, National University of Malaysia, Bangi Selangor, Malaysia

Abstract. Recent evidences suggest functional thoracic hyperkyphosis (FTH) could be a different approach in the management
of subacromial impingement syndrome (SIS). This case study aims firstly with the development of evidence informed FTH model
for SIS. Secondly this study aimed to develop well defined multimodal physical therapy intervention for FTH and its related
mechanical consequences in elderly patient with chronic SIS. As a result, Level IV positive evidence was found in both the short
and long-term pain and disability of chronic SIS, using FTH model with 26 months of follow-up.

Keywords: Subacromial impingement, functional thoracic hyperkyphosis, pain

1. Introduction Repetitive overhead arm elevation [105] especially

Subacromial impingement syndrome (SIS) due to
subacromial space compromise considered as a pre-
dominant mechanical contributing factor in the devel-
opment and maintenance of chronic rotator cuff le-
sion [122]. The reported prevalence of SIS among the
rotator cuff lesions accounts 4465%, often occurs
with prolonged painful arc sign and shoulder move-
ment dysfunctions [74].
Corresponding author: M. Nagarajan, MPT, Department of Phys-
iotherapy, MAHSA University College, Level 1 Block C, Jalan
University Campus, Jalan Elmu Off, Jalan University, Kuala Lumpur
59100, Malaysia. Tel.: +603 7965 2539; Fax: +603 7960 7995;
E-mail: nagupt@gmail.com.
with 10% or more of work cycle [112] is the most
evidenced functional cause for decreased subacro-
mial space. Pathophysiological mechanisms [61] in-
duced by decreased subacromial space are: increased
intramuscular pressure [60,107], local muscular fa-
tigue [106], and impaired local circulation [2,157].
The clinical characteristics of scapular dyskinesia [53,
125,134] such as depressed, anteriorly tilted, down-
ward and internally rotated scapula; elevated clavi-
cle; superiorly migrated humerus; aberrant scapulotho-
racic neuromuscular recruitment and myofascial trig-
ger point are the most evidenced biomechanical and
neurophysiologic factors that maintain ongoing pain
sensitization in patient with chronic SIS. Latest study
showing positive influence of manual scapular assis-

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228 M. Nagarajan and P. Vijayakumar / Functional thoracic hyperkyphosis model for chronic subacromial impingement syndrome
tance test [124] on arm elevation further proves the till
date emphasis on scapular dyskinesia in SIS.
Exaggeration of thoracic kyphosis angle (> 40 ) in
relation to age is called postural/functional thoracic hy-
perkyphosis [150]. Prevalence of Functional Thoracic
Hyperkyphosis (FTH) in elders is 20% to 40% [136]
with the progressive increase from age of 40 years [37].
The reported mean of FTH angle is 43 in women
aged 55 to 60 years and, 52 in 76 to 80 years of
age [34]. FTH may develop from both muscle weak-
ness and spondylosis which may often lead to impaired
mobility, performance and quality of life among the el-
ders [67].
History of evidences [27,33,46,49,63,68,71,82,84]
strongly supports the correlation between FTH and
scapular dyskinesia, particularly in elders > 45 years.
Studies show increased probabilities of acromian im-
pingement during shoulder elevation activities among
the individuals with FTH [36,40]. Positive correlation
between the impaired thoracic extension mobility and
SIS also was recently evidenced [139].
Routine musculoskeletal examinations always con-
sider FTH among all shoulder pain population. But it
could be argued that, how often FTH is considered
in the management process of SIS. Since FTH seems
to be the most predominant factor that maintains the
scapular dyskinesia, the intensive management target-
ing recovery of FTH and its mechanical consequences;
maintenance of normal thoracic posture during thera-
peutic exercises involving arm elevation must have vi-
tal role in reducing recurrence and long-term prognosis
of pain and disability in SIS, particularly in elders.
Looking at the interventions, moderate evidences for
specific exercise management [75,135], limited evi-
dence for the use of shoulder manual therapy [65] and
thoracic and rib mobilization [3,5,64] were available
for SIS related pain and disability.
Since clinical manifestation of chronic SIS seems to
be multifactorial, appropriate pattern recognition, clin-
ical estimation of contributing factors, diagnosis and
decision making remains as unique challenge [29,131].
This ensures the importance of multifactorial conser-
vative management in chronic SIS. Particularly in el-
ders > 45 yrs with [38] the history of gradual onset,
prolonged symptoms and severe pain, weakness and
loss of shoulder movement, the evidence for successive
conservative approach still limited and remains chal-
lenging [76,142].
Conclusions from Level I evidences [75,135] signif-
icantly stress the need for well-defined exercise inter-
ventions based on a structured decision-making pro-
cess with clearly-defined clinical patterns of SIS. Need
for valid and practical classification system with spe-
cific outcome measures for pain, activity and participa-
tion restrictions for shoulder disorders are still recom-
mended strongly. Contemplating on treat the cause
concept in SIS with current evidences, the finding from
this case study will;
1. Introduce evidence informed case specific func-
tional thoracic hyperkyphosis model for chronic
SIS.
2. Provide fundamental Level IV evidence for ef-
fectiveness of well-defined manual and exercise
interventions targeting FTH and its relative con-
sequences in the patient with chronic SIS.
2. Subjective examination
2.1. History and pain evaluation
A 55 year old female, diagnosed as right grade-
I supraspinatus tear and acromioclavicular joint hy-
pertrophy visited physiotherapy department with se-
vere painful movements in the right shoulder since
3 months which was gradual in onset. The patient past
medical history revealed with mechanical neck and bi-
lateral interscapular pain since one year. Patient dis-
continued all household work since one month. Expec-
tation of the patient was to get involved in the normal
ADL and family life. Refer to Fig. 1 for pain distribu-
tion and Table 1 for details of pain description.
2.2. Outcome measures
Visual Analogue Scale (VAS) and Quick DASH [6,
7,30,62] were measured on the first day before treat-
ment. Post intervention was taken on 2nd , 4th , 8th ,
12th week initially during the treatment and, further
follow up on 11th , 16th , 22nd and 26th months (Table 2).
Patient responded for the 10 of 11 items in general
module and all the items in the work module of Quick
DASH. VAS measurement was also considered before
and after every intervention session.
3. Objective examination
Observation reveled age related exaggeration of tho-
racic kyphosis, forward headed posture, round shoul-
ders, right anteriorly prominent humeral head and ster-
nal end of clavicle, and depressed scapula.
 M. Nagarajan and P. Vijayakumar / Functional thoracic hyperkyphosis model for chronic subacromial impingement syndrome 229

Table 1
Physiotherapy diagnosis based on the International Classification of Functioning and Disability (ICF) [20]
Structural Right supraspinatus Grade I tear and, right acromioclavicular joint hypertrophy
impairment Superior migration of humeral head and, reduced right subacromial space
Forward head posture with mild functional thoracic kyphosis
Elevated 1st and 2nd rib at right side
Left flexion-rotation-side flexion (FRS-left) positional dysfunction of T1 and T2
Functional Grade IV tenderness during skill rolling over T1-T7 (Rt)
impairment Grade-II tenderness at upper four sternocostal junction
Right upper Spontaneous pricking pain at suprascapular region, C7-T2 up to acromion process
quadrant pain Spontaneous sharp cramping interscapular pain between T4-T7 (Rt > Lt)
(sensory Sharp, pinching pain at antero-lateral shoulder region
impairment) Dull, poorly localized ache at postero-lateral shoulder region
Deep, dull ache at lateral deltoid region
Slight pin-prick referred pain over lateral arm, forearm region
Pin and needle at palm (occasional, especially at night)
Right upper End range pain and apprehension on all active shoulder movement
quadrant Painful (VAS-8) passive and active medial rotation; horizontal adduction; arm lowering.
movement Sharp, cramping and deep aching with shoulder flexion, abduction and both rotation.
impairment
Painful (VAS-8) restriction of active and passive neck extension, with referred pain over the right superior angle of scapula
and interscapular region
Painful and restricted right lateral flexion and rotation of neck with interscapular pain
Restricted thoracic spine extension and upper rib (1st , 2nd and 3rd ) mobility, expiration more than inspiration.
Painful (Grade-IV) and restricted joint play over C7-T1 transverse process; 1st and 2nd Rib angle; CV and CT joint with
referred pain over the right interscapular region (T4-6).
Painful (Grade-I) and restricted unilateral PA joint play over C5-C7 (Rt) with referred pain over right superior angle of
scapula.
Painful (Grade-II) and restricted postero-anterior joint play over T4-T7 (Bilateral)
Restricted antero-posterior joint play of humeral head on glenoid
Pain (Grade-II) and absence of joint play at acromioclavicular joint
Normal sternoclavicular joint play with anterior displacement of sternal end of clavicle.
Right upper Inhibition of serratus anterior, lower trapezius and deep cervical flexor muscles
quadrant motor Grade 3 muscle power on infraspinatus, subscapularis, rhomboids with mild tenderness.
impairment Grade 4 muscle power on biceps and triceps muscles weakness with mild tenderness.
Active trigger point with taut band and Grade-IV tenderness at lower infraspinatus and long head of triceps with respective
referred pain
Over active deltoid and upper trapezius and levator scapulae with Grade-I tenderness.
Tight levator scapulae, pectoralis major and minor, scalene muscles.
Myofascial tightness on right and left anterior neck region and lateral thoracic region.
Grade-II tenderness and spasm over the cervico-thoracic paraspinal region
Activity Unable to elevate and rotate the right arm; Unable to control the arm lowering
limitation Unable to carry out activity of daily livings
Participation Not involving in Household works; Not willing to work due to pain
restriction Not able to sleep on right side and disturbed sleep
Personal Fear about major diseases; Depression and highly worried about resting pain
factors Dissatisfaction about quality of active life
Environmental Positive family environment; Good economic back ground; Housemaid support
factor

3.1. Physical examination
Functional movement observation revealed signifi-
cant painful apprehension towards elevation, arm low-
ering and rotation activities. During right scapulo-
humeral rhythm there was significant reduction in up-
ward rotation and internal rotation of scapula, devia-
tion of arm towards horizontal adduction (flexion), pre-
mature humeral elevation and cervico-thoracic ipsilat-
eral lateral flexion behaviors were observed. Side flex-
ion and rotation movements of neck were moderately
restricted without any radicular pain. No step sign, sul-
230 M. Nagarajan and P. Vijayakumar / Functional thoracic hyperkyphosis model for chronic subacromial impingement syndrome

Table 2
Values of outcome measures
Outcome measures Pre treatment Post treatment (26 month follow-up)
1st week 2nd week 4th week 8th week 12th week 11th month 16th month 22nd month 26th month
VAS (10 point) 8 5 3 3 2 1 1 1 1
Quick DASH: 45% 32.5% 25% 20% 7.5% 5% 2.5% 0% 0%
general module
Quick DASH: 50% 25% 25% 18.75% 12.5% 0% 0% 0% 0%
work module
(house hold works)

Fig. 2. PA and lateral view of thoracic spine. (Colours are visible

in the online version of the article; http://dx.doi.org/10.3233/BMR-
Fig. 1. Pain distribution. (Colours are visible in the online version of
130373)
the article; http://dx.doi.org/10.3233/BMR-130373)

cus sign were noticed at right shoulder. Refer to the
Table 1 for the detailed palpation; movement exami-
nation; muscle inhibition, weakness and tightness find-
ings.
The provocative tests revealed positive findings with
painful arc and drop arm sign; empty can, Hawkins-
Kennedy, Neers and horizontal adduction test [1]. Iso-
metric strength testing were showed marked weakness
with full can test, lateral rotation and lift-off strength
test.
X-Ray findings revealed mild degenerative changes
on thoracic spine, FTH (Fig. 2); positional malalign-
ment in cervicothoracic, upper costovertebral (CV) and
costotransverse (CT) joints (Fig. 3). MRI shoulder was
interpreted with Grade I right supraspinatus tendon
tear and acromioclavicular joint hypertrophy (Fig. 4).
4. Intervention
From the available evidences patient specific FTH
model for SIS were developed (Appendix-I) and in-
terventions were planned accordingly. The patient was
informed about the 12 weeks (34 time/week) of in-
tervention, long term follow-up and informed written
consent was obtained.
Long duration complaints (physical and functional
impairment) with history of gradual onset were sug-
gestive of both central and peripheral mechanisms be-
ing responsible for the ongoing symptoms) Though the
correlation between the psychological, environmental
factors and the pain severity were poor (8 on VAS) ini-
tially cognitive functional therapy (CFT), was con-
sidered in the form of patient education to improve
the understanding between pain, disability and need of
planned intervention.
 M. Nagarajan and P. Vijayakumar / Functional thoracic hyperkyphosis model for chronic subacromial impingement syndrome
Fig. 3. Enlarged PA view of upper thoracic spine with costovertebral
and costotransverse joint dysfuctions. (Colours are visible in the on-
line version of the article; http://dx.doi.org/10.3233/BMR-130373)
Fig. 4. MRI right shoulder with grade 1 supraspinatus tear and ACJ
hypertrophy. (Colours are visible in the online version of the article;
http://dx.doi.org/10.3233/BMR-130373)
Initially mobilization procedure [90] was used to im-
prove the extension mobility at the cervical and tho-
racic regions. Secondly T1-T2 CV and CT dysfunction
were treated with Maitland GD [90] concept using the
HVLT positions [110]. Thirdly, left FRS dysfunction
and related rib torsions were treated with the guide-
lines of Timothy [144]. Fourthly clavicle mobilization
over the sternal and acromian end [66,89]; and humeral
head mobilization [90] was performed. Finally right
posterior glenohumeral capsule stretch was performed
using post isometric relaxation method (PIRT) in com-
bination with static posterior glide using the guidelines
by Kevin [72]. No discomfort was noticed during the
above procedures throughout the interventions.
After articular mobilization, neuromuscular thera-
pies (NMT) were applied using direct inhibitory pres-
231
sure (DIP) with concept of strain counter strain (SCS)
with guidelines of Leon Chaitow [79]. Deep friction
massage (DFM) was applied in a relaxed muscle state
to deactivate the trigger point (TrP). Combination of
PIRT and myofascial release techniques (MRT) were
used with the guidelines of Leon Chaitow and Craig
Liebenson [80] and Carol [18] to achieve normal neu-
romechanical recovery in tight and overactive muscles.
After soft tissue mobilization, neuromuscular train-
ing was carried out using specific inhibitory and facil-
itation procedure. Initially elastic proprioceptive tape
was applied to facilitate neutral thoracic spine pos-
ture, scapular posterior tilt and, to inhibit the deltoid
and upper trapezius muscles [24,28,56,59,97,98,126].
Secondly individual lower trapezius and serratus ante-
rior facilitation using interferential therapy (2000 KHz,
Unipolar method, 10 mins each muscle) combined
with repeated active shoulder abduction and flexion
movement was considered. Finally, active and self-
assisted training were given for subclavius, serratus an-
terior, lower trapezius and rotator cuff muscles.
FTH corrective exercises were developed as home
exercise using selective modifications from Spinal
Proprioceptive Extension Exercise Dynamic (SPEED)
program [128,129]. The exercise was adapted from the
SPEED protocol used by Benedetti [8] and modified as
per the need of this patient targeting the spine align-
ment, rib torsions, scapulothoracic and rotator cuff
muscle management. Refer to Appendix-II for detail
description of above interventions. The home exercise
was advised for lifetime for the both shoulder, with
more emphasize for right shoulder.
5. Results
Significant progressive reduction in shoulder girdle
pain and disability was observed (refer to Table 2) in
both the short and long-term outcome from the speci-
fied physiotherapy management using FTH model.
6. Discussion
Increasing prevalence and poor outcomes in patients
with chronic SIS still demands successful alternative
modes of conservative management. Above finding ev-
idences the importance of multifactorial pathomechan-
ics that can mislead the clinician who consider the
supraspinatus tear as main source for pain and dis-
ability. Estimating these multifactorial findings could
232 M. Nagarajan and P. Vijayakumar / Functional thoracic hyperkyphosis model for chronic subacromial impingement syndrome
be more difficult since all could influence subacromial
space with similar or non-similar pain pattern [29].
Thus insight on variation in symptoms with its respec-
tive mechanism is more vital to optimize diagnostic
and treatment strategies in chronic SIS. Relating the
FTH as one of the predominant mechanism that could
maintain other contributing factors of SIS, therapeutic
implication of available evidence targeting FTH cor-
rection shows crucial role in long-term recovery of this
patients with chronic SIS. As this is a first study to use
the FTH correction as a major tool for long term recov-
ery of SIS, results of this study can be argued with pre-
vious studies that correlate the current pain and disabil-
ity patterns with postural impairment related treatment
manifestations.
The principle link between structural alignment and
impairment states that, alignment deviations are likely
to be linked to impairment only through movement
dysfunction [120]. Sharmans [120] above statement
further supported by Greenfield et al. [47] that tho-
racic postural impairments are seen as a predisposing
factor for shoulder dysfunction. Though above state-
ments are nonspecific towards SIS, studies by Meurer
and Grober [93] and Betz and Grober [10] supports
the restricted thoracic movement as a cause in SIS.
Most recent reviews by Ludewig and Jonathan [84],
Ludewig and Braman [83] and Seitz et al. [124,125]
states that thoracic joint mobilization may be another
rehabilitation approach to be considered in SIS. Clin-
ically this sounds more feasible since suggested re-
quirement of normal thoracic extension during unilat-
eral arm elevation is only 9 10 and approximately
15 for bilateral arm elevation regardless of age [25,
132,149]. The positive long-term disability recovery
observed in this patient with intensive FTH manage-
ment coincide with the results of many earlier stud-
ies that supports thoracic kyphosis management in im-
proving shoulder elevation [16,120,152]. The articu-
lar mobilization indicated on thoracic spine in this pa-
tient and improvement in thoracic spine extension (in-
directly informed from the long-term shoulder func-
tional recovery) can be well supported by the recent
work of Ivan Bautmans [58].
Influence of cervical, thoracic facet dysfunction and
its role in persistent pain on shoulder girdle and tho-
racic region are well aware by musculoskeletal clini-
cians. Looking into the normal biomechanics, the up-
per thoracic (T1) T2-T7 ipsilateral side flexion and
rotation is the commonly observed kinematic chain
movement during arm elevation [132,141,156]. During
normal cervico-thoracic and thoracic spine lateral flex-
ion the ipsilateral upper ribs approximate; glides su-
periorly at CV and CT joints; rotate anteriorly at the
CT joint as the ipsilateral transverse process glides in-
feriorly. Similarly, during normal thoracic spine flex-
ion, the ribs rotate anteriorly (anterior rib torsion) at
the CT joints and glide superiorly at the CV and CT
joints [78,108,121]. Above normal kinematics corre-
lates the documented physical findings (Table 1) of this
patient such as specific muscle tightness and spasm,
restricted facets and upper rib mobility as a compen-
satory maladaptation due to routine demand of shoul-
der girdle with FTH related dysfunctions. This mal-
adaptation may further aggravate the ongoing routine
stress on right shoulder girdle.
Other than the cervical and thoracic spine induced
scapulohumeral joint stress, it can be hypothesized that
the FTH and repetitive shoulder movement induced
anterior rib torsion could further cause the following
chain mechanical consequences related to SIS such as;
Rotation and side flexion torsion on sternum; thus
may influence the SCJ
Anterior malalignment of the sternal end of clavi-
cle, thus protraction and anterior rotation of clav-
icle (due to sternal rotation)
The resulted side flexion of sternum could cause,
inferior malalignment of sternal end of clavi-
cle thus elevation of clavicle and, increased lat-
eral long axis forces on clavicle, thus increased
acromioclavicular joint compressive force.
Maladaptive protraction (internal rotation) and
anterior tilt of scapula due to above clavicle
malalignment.
The influence of above hypothesized maladaptation
could cause cumulative stress on acromioclavicular
joint and subacromial space. Though there are insuf-
ficient evidences to support the above rib torsion in-
duced hypothetical compensation, it is still logic to
correlate the right upper rib anterior torsion induced
sternal and clavicle compensatory changes as a core
cause for prominent right sternal end of clavicle; right
acromioclavicular joint hypertrophy and supraspinatus
tear in this patient. Hence, addressing and managing
the cervical and thoracic spine facet joints; costover-
tebral and costotransverse joints, and sternoclavicular
and acromioclavicular dysfunctions in this patient can
be very well rationalized.
Pain characteristics of cervical and thoracic facet
dysfunctions are well explained by Fukui et al. [41,
42]. Referred pain over the neck-shoulder junction is
from C4/5, C5/6; suprascapular region is from C4/5,
C5/6, C7/T1, T1/2; superior angle of the scapula is
 M. Nagarajan and P. Vijayakumar / Functional thoracic hyperkyphosis model for chronic subacromial impingement syndrome
from C6/7, C6, C7/T1, T1/2; mid-scapular region is
from C7/T1, T1/2, T2/3. Referred pain distribution
of C7/T1 to T2/3 shows significant overlap. On the
other side, the reported pain characteristics of the up-
per CV and CT joint dysfunction are, localized pain
on posterior thorax; radiating pain to the anterior chest
wall; pain with deep breathing, coughing/sneezing; in-
creased pain with flexion, rotation, and ipsilateral side
flexion; tenderness at CT joint and rib angle [123,145].
The pain patterns of upper (T1 and T2) CV and CT
joints commonly overlap with C4-T2 facet dysfunc-
tion [14]. Importance of differential pain identification
and treatment of pain in upper thoracic region with
above joint dysfunction in this patient could be ratio-
nalized [39].
Linking with above normal kinematic coupling in-
formations, the correlation between the clinical man-
ifestations of 1st and 2nd rib articulation (Table 1)
and neck movement behaviors (painful and restricted
right side bending and rotation) evidences the diag-
nosed FRS-left dysfunction and its management with
the guidelines of Greenman [48] and Timothy [144] to
improve the overall ongoing pain sensitization and dis-
ability.
Achieved short-term recovery on cervical and tho-
racic region related pain with these spine mobilizations
could be supported by the good clinical predictability
of this patient cervical dysfunction which is grade III
tenderness, hypomobility of T1, negative upper limb
tension test, and female [118]. Further short-term use
of thoracic spine mobilization on cervical dysfunction
related pain syndromes are well supported in the latest
systematic review by Cross et al. [26].
Effective long-term recovery of suprascapular, su-
perior angle of scapula and interscapular pain sensi-
tization and specific muscle over activity; increased
rib mobility; and over all shoulder function observed
in this patient following non-thrust thoracic facet and
CV joint mobilization in combination with other men-
tioned treatments coincide with the results of clini-
cal studies by Kelly and Whitney [70]; Haddick [50];
Strunce et al. [133]; Mintken et al. [95] and, physio-
logical statements by Mclain [92] and Lawrence [77].
Especially the long term recovery of shoulder pain and
disability in this patient through standard articular mo-
bilization procedures indicated in this patient supports
the latest study by Caldwell et al. [17] and Bennell et
al. [9].
Clavicular movements in relation to thorax (at ster-
noclavicular joint) and in relation to the scapula (at
acromioclavicular joint) during the arm elevation ac-
233
tivities among the healthy individuals are well de-
scribed by the Sahara et al. [119]; Teece et al. [137]
and Ludewig et al. [84]. The commonly observed clav-
icular movements in relation to thorax are, 30 of pos-
terior long axis rotation; 9 10 of elevation and 9 of
retraction. The respective coupling patterns of scapula
to above clavicular movements are, 20 30 of upward
rotation and 10 of posterior tilt; 6 of anterior tilt and
9 external rotation approximately.
Though the above evidences are sufficient enough to
support the influences of clavicle position and move-
ment in scapular dyskinesia; the earlier hypothesis on
influence of anterior rib torsion on sternum and clavi-
cle position, thus the sternoclavicular joint movements
still need further evidences. Presence of prominent
right side sternal end of clavicle found in this patient
and above informed evidences may support the need
and effectiveness of articular mobilization indicated at
the sternal and acromian end of clavicle. Also recent
evidence on influences of sternoclavicular joint disor-
ders on shoulder impingement can be a further sup-
port for importance of clavicle mobilization indicated
in this patient [138].
From the evidences showing the positive correla-
tions between FTH, pectoralis minor length, scapular
kinematics and impairments of SIS [1113,95,130], it
is strongly arguable that presence of scapular dyskine-
sia can be the consequences of FTH. Altered length
tension relationship due to scapular dyskinesia may
further cause scapulothoracic and rotator cuff muscles
dysfunction and further reduces the subacromial space,
aggravate the intrinsic subacromial tendon degrada-
tion [89,94,101].
Moreover the importance of recovering neutral po-
sition, normal osteokinamatic patterns of scapula and
its related scapular muscles performance in SIS are
well described in many clinical studies [45,53,73,83
85,87,111,125,134,143]. The importance of humeral
head neutral position, normal arthrokinematics and its
related demand on glenohumeral capsule and rotator
cuff function in SIS are well evidenced in many clin-
ical studies [31,43,51,52,69,85,91,101103,146148].
Above evidences on scapulohumeral kinematics and
its relevance on muscular performance are more suffi-
cient to support the prescribed neuromuscular facilita-
tory and inhibitory training; stretching and strengthen-
ing exercises; glenohumeral joint mobilization towards
recovery of normal kinematics in this patient.
Prescription of upper trapezius inhibition taping and
active neuromuscular facilitation targeting the serra-
tus anterior and lower trapezius can be directly argued
234 M. Nagarajan and P. Vijayakumar / Functional thoracic hyperkyphosis model for chronic subacromial impingement syndrome
with evidence links between the presences of abnor-
mal scapular kinematics, decreased electromyographi-
cal performance and increased latencies of above mus-
cles in patients with SIS [2123,32,96,86,117,151].
The long term prognosis observed in overall shoul-
der function with scapular muscle facilitation in this
patient coincides with the recent study by Baskurt et
al. [4].
Effect of infraspinatus TrP deactivation and rotator
cuff exercises can be argued with the evidenced cor-
relations between the proximal migration of humeral
head, decreased abduction torque, progressive de-
crease in rotator cuff performance and co activa-
tion [19,31,81,89,101,113,116,147,153,154], especia-
lly in the infraspinatus muscle [57,100,127]. The effi-
ciency and safeness of rotator cuff and scapular mus-
cles strengthening procedures used in this study can
be well supported by the work of Escamilla [35] and
White et al. [155]. Long term positive outcome in pain
and disability of this patient with the integrated use of
specific rotator cuff and scapular stabilizer strengthen-
ing exercises coincide with recent randomized control
trail by Theresa Holmgren [55]. The successful use of
TrP deactivation in reducing the right suprascapular,
shoulder and lateral surface of entire arm pain is co-
incide with recent work of Hidalgo-Lozano et al. [54].
The importance of scapular and thoracic spine feed-
back using tactile and verbal cues during the neuro-
muscular facilitation used in this patient can be well
supported by the work of Roy et al. [114,115] and Seitz
et al. [124]. Also the immediate use of inhibitory and
facilitatory taping indicated in this patient can be di-
rectly supported from the work of Thelen et al. [140].
Application of CFT targeting the specific functional
recovery in relation to fear of pain is known for its
effect in promoting self-efficacy towards home exer-
cise; normalization of pain and disability cognitions
and physical performance of chronic pain patients [99,
104].
7. Conclusion
This case report provides Level-IV evidence and
preliminary model for considering FTH as a predomi-
nant factor which may influence maintenance of scapu-
lar dyskinesia thus long term pain and disability in
elderly patients with SIS. Modified SPEED exercise
programme targeting the spine alignment, rib torsion,
scapulothoracic and rotator cuff muscle recovery iden-
tified with optimal long term recovery.
This case report shows the importance of develop-
ing the diagnostic criteria by identifying the subgroups
(eg: FTH subgroup in SIS) with its relevant multifacto-
rial mechanical factors that reflect similar pain, rather
than the repeated emphasize on the effectiveness of
physiotherapy treatment techniques. Also looking at
the heterogeneity of samples in current available ev-
idence, identifying and establishing the evidence in-
formed subgroup in SIS and its related pain patterns
may improve the level of evidence in future research
on conservative management of SIS. Further develop-
ment of this model should be considered to evidence
all the mechanical consequences with its appropriate
measurement and management methods.
Acknowledgments
I would like to thank my colleagues Ms. Melissa
Romer and Mr. Lourdhuraj for their help in review-
ing the manuscript. I also thank to my colleague Mr.
Madhavan Krishnan for his expertise in photography
included in this manuscript. I sincerely thank the pa-
tient for her continuous support and consent for long
term follow-up.
Conflict of interest
There is no authors conflict for this study. No fund
involved for this study
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240 M. Nagarajan and P. Vijayakumar / Functional thoracic hyperkyphosis model for chronic subacromial impingement syndrome

Appendix-I: FTH model for SIS

Presence of Functional Thoracic Hyperkyphosis (FTH)

Associated maladaptive arthrokinematics Associated maladaptive muscular kinetics

Decreased inferior glide at
C7-T7 & C3-C7 facet joints
Superior glide of head and
neck of rib
Increased C7-T1 junction flexion
Increased T2-T7 flexion
Anterior rotation of ribs
Forward head posture
Weak erector spinae, deep
cervical flexor, trapezius and
rhomboids
Tight suboccipital extensor,
SCM and pectoral muscles

Decreased efficiency of ipsilateral side

Compensatory excessive
anterior torsion of ipsilateral
upper rib (1-7)
Approximation of ipsilateral
upper rib
Compensatory excessive
superior glide of head and
neck of rib at CV & CT joints
flexion & rotation due to lack of inferior
facet glide at C3-T7 during arm elevation
& Tightness on ipsilateral
Decreased efficiency of scapulohumeral scalene, levator scapulae to
rhythm during arm elevation activity compensate insufficient
(Especially on dominant hand) lateral flexion and rotation
Tight scalene, pectoralis
Rib torsion induced minor, pectoralis major to
Rotation and Side flexion sternal torsion compensate upper rib
approximation

Restricted posterior glide of
the sternal end of clavicle
Restricted superior and
posterior glide of acromion at
acromioclavicular joint
Reduced upward rotation,
posterior tilt and external
rotation of scapula during
arm elevation
Restricted inferior and
posterior glide of humeral
head during arm elevation
Anterior Misalignment/sublaxation of
sternal end of clavicle; Protraction and Weak serratus anterior, lower
anterior long axis rotation of clavicle and middle trapezius &
rhomboids
Tight pectoralis minor,
Internal rotation, abduction and anterior tilt pectoralis major
of scapula (Scapular dyskinesia)
Altered length-tension
relationship and coactivation
Humeral positional misalignment of the rotator cuff muscle.
(Excessive anterior-superior migration of
humeral head & posterior capsule tightness) Decreased abduction torque
& compensatory deltoid
hyperactivity
Decreased Subacromial Space
&
Subacromial Impingement Syndrome
 M. Nagarajan and P. Vijayakumar / Functional thoracic hyperkyphosis model for chronic subacromial impingement syndrome 241

Appendix-II: Descriptions of interventions

Interventions Description of intervention techniques with parameters

Cognitive behavioural CBT were targeted more specific about the pain stimulating structures and its relationship with movements and
Therapy (CBT) ADL. The mechanics of normal posture and shoulder girdle movement during day-to-day life; role of habitual
(Only once before maladaptation of posture, abnormal movement and muscle function in ongoing pain.
Mobilization treatment)
The lack of ability to actively facilitate isolated shoulder muscle activity and to overcome abnormal movement
pattern (shoulder hiking, thoracic kyphosis, and deviation of plane of movement during abduction) and impor-
tance recovering these abilities for pain free shoulder function.
Articular mobilization Grade III-IV central PA glide at T2-T7 delivered in prone lying; in passive end range thoracic spine extension
and in combined extension-lateral flexion-rotation (both side) positions using patient seated with both hands on
the neck and leaned forward on couch supporting the mid-humerus. Followed by this prone, unilateral PA glide
progressively from Grade II to IV were delivered at both sides (Rt > Lt) of C4-7-T1-T2. Above procedures were
applied using Maitland [90] concept to improve the thoracic and cervical extension related mobility.
Costovertebral and costotransverse joint dysfunctions (left FRS) were treated with prone, Grade II-III left trans-
verse glide at T1-2-3 using Maitland [90] concept, followed by Grade III-IV left transverse glide at T2 & T3 re-
spectively using HVLT positions recommended by Peter Gibbon and Philip Tehan [110]. After that, PA & caudal
glide progressive from grade II to IV were applied at T2 & T3 transverse process in pain free right side bending
and rotation (with in barrier limit) as recommended by Timothy [144].
Left FRS related rib torsion dysfunctions were treated by applying expiration mobilization (passive & active
assisted) to facilitate the right 1st , 2nd and 3rd rib external torsion using the PIRT in supine and sitting position.
Supine, Grade II & III posterior and inferior glide to sternal end; anterior and inferior glide to acromion end of
clavicle MacConaill [88] & Kaltenborn and Evjenth [66] were applied to improve the clavicle retraction; posterior
rotation; scapular upward rotation and posterior tilt.
Grade III humeral longitudinal distraction with stable & elevated acromion 23 times with 60 sec hold; Progres-
sive oscillatory AP glide from grade II to IV was applied at loose pack position, 90 of abduction and flexion po-
sition using Maitland [90] concept to improve subacromial space and humeral kinematics during scapulohumeral
rhythm. Followed by this posterior glenohumeral capsule stretch was considered using PIRT for the above pur-
pose using the recommendations of Leon Chaitow [79]; Craig Liebenson [80]; Kevin [72]. All the above proce-
dures were applied as pain free gentle static, followed by oscillatory glide of 10 repetitions each during every
clinical visit of first 6 weeks interventions.
Soft tissue mobilization Infraspinatus and LHT muscles TrP deactivation were considered individually using DIP for 60 sec in passively
1. TrP Deactivation shortened muscle position with the SCS concept during every clinical visit. Slow DFM with-in tolerable pain
intensity (10 to 15 repetitions, once in week) followed by ice cube massage (3 times/day, 10 min each) was
considered after DIP. Subscapularis tender point treated using DIP.
2. Neuro muscular Combined PIRT and MRT within the pain free range was as applied to pectoralis minor & major, levator scapulae,
flexibility management upper trapezius, scalene muscles and latissimus dorsi. MRT for cervical fascia.
Above procedures was advised to perform twice a day at home with minimum of 23 repetitions for each muscle
whenever possible. Most of the neuromuscular release procedures were considered first on the right side to achieve
pain control in right shoulder. The patient was encouraged to perform above flexibility procedures for left shoulder
also.
3. Neuro muscular The elastic proprioceptive facilitatory taping was applied to facilitate neutral thoracic spine posture and scapular
inhibition & facilitatory posterior tilt. Then the inhibitory rigid tape applied firmly across the deltoid and upper trapezius muscle fibers.
management Taping procedures were followed with guidelines provided by Morrissey [98]; Cools et al. [24]; David Knee-
shaw [28]; Janwantankul and Gaogasigam [59]; Morin et al. [97]; Selkowitz et al. [126]; Hsu et al. [56].
Individual lower trapezius and serratus anterior facilitation using interferential therapy (2000 KHz, Unipolar
method, 10 mins each muscle) combined with active shoulder abduction and flexion exercise in erect sitting were
repeated with appropriate rest in between using Borgs scale (RPE) as a short monitoring tool.
Tactile feedbacks were given on medial border and inferior angle of scapula to facilitate upward rotation and
to control pseudo winging/anterior tilt of scapula. Verbal feedback was given to keep the neutral thoracic spine
throughout the movement. This is considered to ensure the appropriate kinematic relearning, with well designed
neuromuscular kinetic relearning.
242 M. Nagarajan and P. Vijayakumar / Functional thoracic hyperkyphosis model for chronic subacromial impingement syndrome

Interventions Description of intervention techniques with parameters

Above taping with interferential therapy was considered during every visit on first 6 weeks.
Deep cervical flexor facilitation using chin tuck exercise in supine and sitting
Manual facilitation procedure using MET to subclavius muscle using resisted inspiration at 1st rib at sternal
end.
Serratus anterior facilitation in supine, side lying and standing position in scapular plane and sagittal plane.
Lower trapezius facilitation in standing facing the close to wall with both upper extremity placed in flexion
with full extremity in wall contact, from this position the patient was informed to with draw the palm about
0.5 cm and hold for possible time. The same procedure was repeated in prone lying as home exercise.
Multi level progressive isometric rotator cuff strength training within the pain free range using wall assistance.
During this exercise patient was strictly advised to consciously maintain the thoracic spine in neutral extension
as possible. Isometric rotator cuff exercises were prescribed in shoulder in neutral, within the 30 degree of
abduction.
Supraspinatus isometric strength training: Five degree of shoulder abduction against wall resistance was
advised in standing/sitting position with neutral shoulder rotation and full elbow flexion, using lateral elbow
as a contact point.
Subscapularis and infraspinatus isometric strength training: Standing/sitting position with neutral sagittal
and coronal plane shoulder alignment, elbow 90 degree flexion and using fisted hand as a contact point
against wall resistance. This exercise was prescribed in neutral rotation, and throughout the available rota-
tion with multiple positioning.
Shoulder neuromuscular co-activation exercises: Wall press in 90 degree flexion and abduction position.
Each individual facilitation procedure were advised as a home exercise twice a day with 58 slow repetition. The
patient was strictly advised to repeat the exercise as tolerable by using the RPE as a quick monitoring tool.
Modified SPEED Ice cube massage for infraspinatus and long head of triceps were advised before this exercise.
home exercise
protocol for SIS
Self thoracic postural correction: Supine lying with knees and hips flexed and feet on the floor, small news paper
roll of 58 cm diameter thickness cover by towel perpendicularly placed under the 5th to 7th thoracic vertebrae for
minimum of 1015 minutes or depends on the patient capacity. During this procedure the patient was informed to
support the head with comfortable towel folding. This procedure was strictly adapted by patient as a pre postural
alignment and above rotator cuff exercise procedure at home.
Modified FTH corrective exercise for SIS individuals: Below exercises were taught appropriately by the clinical
therapist and analyzed on the patient in regards to movement performance. Each exercise was advised to repeat
510 times within the pain free range based on RPE. Patient was asked to perform this exercise twice a day at
home, and encouraged to perform the same in early few clinical visits to assure the efficiency of exercise related
movement performance.
1. Supine with towel role as mentioned above, posterior pelvic tilt exercise with isometric hip adductor and
bridging exercise (Head supported with comfortable towel folding)
2. Supine with towel role as mentioned above, pain free chin retraction exercise and chin tuck exercise (Head
supported with comfortable towel folding)
3. In a sitting position with hands hooked at the chin level, deep breathing- in exercise combined with left neck
and thoracic spine rotation, then back to the initial position
4. In a sitting position with arm along the sides, deep breath-in exercise combined with pushing both scapula
backwards combined with chin retraction, then back to the initial position
5. In a sitting position with ninety degree flexed elbows, deep breath-in exercise combined with shoulder exten-
sion, adduction, chin retraction and neck extension, then back to the initial position.
6. In a sitting position with ninety degree flexed elbows, deep breath-in exercise combined with shoulder lateral
rotation combined with scapular retraction and chin retraction then back to the initial position.
7. In a sitting position with hands behind the head, deep breath-in exercise combined with pushing elbows back-
wards with chin retraction and neck extension, then back to the initial position
8. In a sitting position with hands on thighs, deep breath-in exercise combined with shoulder abduction with
palms facing upwards, then pushing the both scapula backwards.
9. In a sitting position holding a stick in two hands, deep breath-in exercise combined with raising the stick
towards flexion.
10. In a sitting position with arms along the sides, lateral bending of the trunk while trying to touch the floor with
fingers from one side to the other.
11. In a standing position in front of a wall, arms overhead wall slides combined with neck extension.
12. In a standing position with back touching the wall, starting from 90 shoulders abduction and 90 elbows flexion,
complete shoulder abduction and elbow extension bringing hands over head .
13. In a standing position with forearms on table, alternate hip extension with knee in slight flexion.
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