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Evaluation and Management of Scapular Dysfunction

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Evaluation and Management of Scapular Dysfunction INTERNATIONAL ACADEMY OF ORTHOPEDIC MEDICINE VOLUME 3, ISSUE 1 Anatomy and Landmarks for the Superior A Proposed Diagnostic and Middle Classification of Cluneal Nerves: Patients with Application to Evaluation and Temporomandibular Posterior Iliac Management Disorders: Crest Harvest of Scapular Implications for Physical and Entrapment Dysfunction Therapists Syndromes IAOM-US CONNECTION DIRECTORY is published by John Hoops PT, COMT The International Managing Editor Academy of Orthopedic Medicine-US (IAOM-US) Valerie Phelps PT, ScD, OCS, FAAOMPT PO Box 65179 Chief Editor / Education Director Tucson, AZ 85728 (p) 866.426.6101 Tanya Smith PT, ScD, COMT (f) 866.698.4832 Senior Editor (e) [email protected] (w) www.iaom-us.com John Woolf MS, PT, ATC, COMT Business Director CONTacT (p) 866.426.6101 Sharon Fitzgerald (f) 866.698.4832 Executive Assistant (e) [email protected] (w) www.iaom-us.com Andrea Cameron All trademarks are the property Administrative Assistant/ of their respective owners. Marketing Liaison The IAOM-US CONNECTION VOLUME 3 CONNECTION Admin Comment: Greetings to all of our colleagues from the IAOM-US team! 2014 was a year of learning and growing for the IAOM, and we’ve accomplished some exciting things. Starting in January 2015, all of our 12 orthopedic manu- Evaluation and Management al therapy courses will be Hybrid courses, with 8 hours of Scapular Dysfunction of online content in addition to two days of traditional hands-on course. This also means that we 2 will be offering 12 stand-alone 8-hour online modules that correspond to these courses. Colleagues have told us that they really appreciate the flexibility the new hybrid format brings. A Proposed Diagnostic We are continuing to create a strong partnership with Classification of Patients our colleagues in Chile in an effort to provide IAOM with Temporomandibular content to Latin America. Look for more exciting devel- Disorders: Implications opments in this arena in 2015. 7 for Physical Therapists If you haven’t had a chance to check it out, our 2015 courses are now listed on our website www.iaom-us. com. And, we’re planning to run some discount promo- tions that will EXCLUSIVELY be posted on Facebook, so Anatomy and Landmarks be sure to Like our Facebook page so you don’t miss for the Superior and Middle out. Cluneal Nerves: Application to Posterior Iliac Crest Harvest And lastly, we’re very excited to announce a new 13 feature of the IAOM-US Connection – the addition of a and Entrapment Syndromes “Letters to the Editor” section. One of the goals of the IAOM-US editorial staff is to facilitate conversations about the clinical commentaries. We would like to invite readers to write in and start a dialogue about the con- tent of the connection. All letters should be scholarly in nature, and should address a relevant topic that you’ve seen in past publications. Conversely, if there’s a topic you’d like to see us address, we’d love to hear that, too. Anything that’s on your mind in the orthopedic manual therapy world - let us know! Letters will be approved by the editorial staff and we will also invite the author for a follow up response. Tell us what you think! email: info@ iaom-us.com. The entire IAOM-US team appreciates your continued support and wishes you a healthy and prosperous 2015!! Cheers! Sharon & Andrea INTERNATIONAL ACADEMY OF ORTHOPEDIC MEDICINE Evaluation and Management of Scapular Dysfunction McClure P, Greenberg E, Kareha S. Sports Med Arthosc Rev. 2012;20:39-47. Abstracted by Matt Stump, PT, ScD, COMT, CSCS, Camarillo, California - Fellowship Candidate, IAOM-US Fellowship Program & Jean-Michel Brismée, PT, ScD, OCS, FAAOMPT, Fellowship Director, IAOM-US Fellowship program. INTRODUCTION Scapular motions are frequently described by three pri- In this article, the authors set out mary rotations: Upward/downward rotation (Figure 1), anterior/posterior tipping, and internal/external rotation to review normal scapular motion, (Figure 2). Upward/downward rotation occurs around describe key elements of an an axis that is perpendicular to the plane of the scapula examination for scapular and is the greatest and easiest to observe. Anterior/poste- rior tilting occurs around an axis that is through the spine dysfunction and address of the scapula where anterior tilting appears as winging of associated intervention strategies. the inferior scapular angle and posterior tilting involves 2 IAOM-US CONNECTION | International Academy of Orthopedic Medicine IAOM-US CONNECTION the inferior angle of the scapula moving anteriorly while GH joint is primarily responsible for the motion. the superior border moves posteriorly. Scapular internal/ Scapular motion is achieved via muscular force couples. external rotation occurs around a vertical axis. Move- Upward rotation is controlled primarily by a force couple ment of the medial border of the scapula away from the between the upper and lower trapezius and the serratus thoracic wall is termed scapular internal rotation. The anterior (Figure 3) whereas the lower fibers of the ser- scapula demonstrates a consistent pattern of upward ratus anterior and lower trapezius are thought to produce rotation, posterior tilting, and external rotation through scapular posterior tilting; the middle trapezius is thought arm elevation. However, the greatest amount of scapu- to produce scapular external rotation. lar motion occurs after 90° of arm elevation when the contribution of glenohumeral (GH) motion and scapular motion are almost equal. Below 90° of arm elevation the Figure 3. Upward rotation is controlled primarily by a force couple between the upper and lower trapezius and the serratus anterior. Figure 1: Upward/downward rotation (From: Wikimedia Com- mons, public domain). The goal of shoulder girdle examination is not only to identify abnormal scapular motion or positioning, termed “scapular dyskinesis”, but also to determine whether the abnormal motion correlates with the pa- tient’s complaints of symptoms. Clinical evaluation of scapular dysfunction should include three basic elements: (1) visual observation; (2) the effects of manual correc- tion of dysfunction on symptoms; and (3) evaluation of surrounding anatomic structures potentially responsible for dyskinesis. The Lateral Scapular Slide Test has been used to assess the side-to-side differences from the inferior angle of the scapula to the spinous processes. The distance from the inferior angle to the spinous process most directly horizontal from it is measured. The test is performed in three different positions and a side-to-side difference of > 1.5 cm is considered pathological; however, the validity Figure 2. Internal/external rotation. of this test has been questioned for three main reasons: (From: Wikimedia Commons, public domain). (1) both symptomatic and asymptomatic individuals can IAOM-US | CONNECTION 3 demonstrate asymmetry; (2) the possibility of bilateral performed by manually positioning and stabilizing the pathologic dyskinesis; and (3) the dynamic and three- entire medial border of the scapula on the thorax, in a dimensional nature of scapular movement is not assessed retracted position. The test is considered positive when with a static test. there is a decrease in pain or increased shoulder elevation strength when the scapula is stabilized during isometric The Scapular Dyskinesis Test (Figure 4), a visually based arm elevation in the scapular plane at 90°. test, involves a subject performing weighted shoulder flexion and abduction movements while visual observa- tion of the scapula is performed. The test consists of characterizing scapular dyskinesis as present or absent. The presence of winging or dysrhythmia was considered positive for dyskinesis. Figure 6. Scapular reposition test. Isometric elevation strength is tested with manual pressure on the scapula encouraging posterior tilting and external rotation by forearm pressure on the medial border. A positive test occurs when strength is substantially in- creased or pain is decreased. Figure 4: Scapular dyskinesis test. The test is performed by the pa- tient flexing against a 3-pound weight and observing for scapular Once the examiner determines that the scapular dyski- winging or dysrhythmia. (A) Obvious dyskinesis (winging) on the nesis is present and contributing to dysfunction, exami- left. (B) Increased dyskinesis on the left. nation of the surrounding tissue should be performed to identify factors that might be responsible for causing the altered scapular motion. Factors to consider include Because scapular dyskinesis has been reported in symp- deficits in strength or motor control of the scapular tomatic and asymptomatic individuals, one must de- stabilizing muscles (serratus anterior, middle trapezius, termine whether the dyskinesis is contributing to an and lower trapezius), postural abnormalities (forward individual’s problem. There are two main tests that do head posture, protracted scapula, and increased thoracic so: The Scapular Assistance Test (SAT) (Figure 5), and kyphosis), and impaired flexibility (pectoralis minor and the Scapular Reposition Test (SRT) (Figure 6). The posterior shoulder tightness). Treatment for scapular dys- SAT is performed by manually assisting scapular upward kinesis includes strengthening both the scapulothoracic rotation and posterior tilting during shoulder elevation and glenohumeral joint musculature with an emphasis and assessing the effect on pain. The test is considered on facilitation of lower and middle trapezius and serratus positive when the pain
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