Assessment & Introduction Rehabilitation with Emphasis on Scapular • Scapular function & Stabilizers biomechanics • Examination Peggy A. Houglum, PhD, ATC, PT • Evidence-Based Rehabilitation Duquesne University Duquesne University Program with Progression Pittsburgh, PA 2007 EATA Workshop Boston, MA

Scapular Function & Purpose of Biomechanics Muscles 1) Provide stable • Three axes of platform for shoulder rotation 2) Move scapula for • 6 Muscles Provide improved shoulder Scapular function & position Stabilization & Scapular Control 3) Prevent subacromial During Shoulder impingement via Motion Neumann, 2002 scapular movement & Donatelli, 2004 position in shoulder elevation

#1 Shoulder Problem Pathomechanics Etiology Changes in 3 planes of 1. Body posture -Ziva & Bezalel, 2001; Finley & Lee, 2003; Satterwhite, 2000; Kibler, 2000; motion Æ impingement Mottram, 1997 2. Neuromuscular alterations –Ludewig & Cook, 2000; Satterwhite, 2000; Mottram, 1997; Sahrmann, 2002 3. Overuse fatigue –DePalma & Johnson, 2003; Satterwhite, 2000; Tsai et al, 2003 4. Muscle imbalances -DePalma & Johnson, 2003; Wang & Cochrane, 2001; Satterwhite, 2000; Kibler, 2000; Sahrmann, 2002

1 Pathology Progression 1. Effects of Body Posture

Abnormal Abnormal biomechanics scapular • Changes scapula position of G-H joint motion • Changes in scapula position & mobility Muscle overuse, contribute to: Altered GH fatigue, & relationship insufficiency Glenohumeral – GH instability Pathologies & – RC tears Excessive Excessive Shoulder demands on – Shoulder impingement demands on RC static stabilizers --Paletta et al, 1997; Warner et al, 1992; Matsen & Arntz, 1990; Itio et al, 1992 • Postural changes are associated with ↑d Excessive joint Wear & Tear shearing forces muscle length –Sahrmann, 2002

Adapted from Ziva & Bezalel, 2001

Forward Head Posture Posture Impact on Scapula • Lengthening of posterior muscles • Protraction of scapula • Tightening of anterior muscles • Anterior tilting of scapula

Δ to ↓ subacromial space

2. Overuse Fatigue & 3. Neuromuscular Its Impact on Scapula Changes • Reduces muscle • Related to: strength and increases – Posture response time -Cools et al, 2002 • Alters mechanics – Repetitive -Tsai et al, 2003; DePalma & Johnson, 2003 • Reduces functional mechanics efficiency – Fatigue -Voight & Thompson,2000; DePalma & Johnson, 2003 • Æ UT elevates scapula before it rotates

2 Altered Neuromuscular Neuromuscular Changes Impact on Scapula Functional & Impaired Restrictive Components • Altered position becomes “normal” Changes Sustained position Posture • Firing sequence and timing are altered Repeated Motion • Incorrect mechanics become more engrained Fatigue • Scapula tilts, elevates, and protracts Impaired Inaccurate Movement Feedback

4. Muscle Imbalances Muscle Imbalance • Changes in scapular muscles Impact on Scapula lead to loss of glenohumeral control –Kibler, 2000; Bast et al, 2000; Su et al, 2004 • Altered firing sequence and timing • Loss of proper scapula motion • Reduced ROM leads to impingement --Wang & Cochrane, 2001; DePalma & Johnson, 2003 • Inappropriate scapula position for • Scapula changes lead to GH elevation: Protracted, anteriorly tilted glenohumeral –Kibler, 2000; Bast et al, 2000; Su et al, 2004; Wang & Cochrane, 2001; DePalma & Johnson, 2003; Ludewig & Cook, 2000; Decker et al, 1999

Scapular Δs Affect G-H Scapular Δs Affect G-H

Ant • Protraction eri or – Protraction occurs with • Ant-Post Tilting Po ste GH elevation Prot – Relative to superior r i o r raction – Allows full contact of border scapula to thorax Re – Occurs with ACJ – Provides additional GH traction – Allows full contact of elevation scapula to thorax • Pathomechanics • Pathomechanics – Tight pec minor + Weak rhomboids Æ Protracted posture – Tight pec minor Æ Ant Tilt – Excessive protraction Æ narrows subacromial space

3 Scapular Δs Affect G-H Scapular Δs Affect G-H • ↑ Rotation • Weak scapula – Occur with GH elevation Æ ↑ Rotation muscles – Allows max. contact of decreased glenoid with humerus stability – Provides additional GH • Stable scapula elevation ROM ↓ Rotation is necessary for • Pathomechanics stable GH joint – Tight pec minor + Weak • Instability Æ subacromial rhomboids Æ <↑ rotation Æ impingement impingement via

Need for Stabilization Pause for Thought: OPTIMAL SHOULDER FUNCTION What is the influence of muscle performance requirements on SCAPULAR rehabilitation? CONTROL & MOTION SCAPULAR STABILIZATION TRUNK STABILIZATION

Muscle Activity Examination • Serratus Anterior: • Serratus Anterior: constant 20-40% delayed activity >3 throughout times normal & bilateral in S.I. freestyle stroke --Wadsworth & Bullock-Saxton, 1997 --Pink et al, 1991 • Scapular instability: • S.A. & Lower – in 68% R.C. Trap = Most problems susceptible to --Kuhn et al, 1995 inhibition – in 100% G-H --Glousman et al, 1988 instability --Warner et al, 1992

4 Examination Posture Observation

• Visual Inspection – Posture – Asymmetry – ROM: Concentric & Eccentric Shoulder Scapula C/S Ribs

Posture Observation Scapula Position on Ribs

Examination: Examination: Strength Scapular ROM • Hips & Trunk: = 54% throw force; c 20%↓→

34% ↑R.C.vel. --Kibler, 1995 • Shoulder • Scapula

5 Examination Screening Tests: Scapula

Scapular Muscle Strength • Isometric Strength --Kibler, 1998 Pinch in retraction X 20s •Serratus Anterior Normal = No burning •Lower Trapezius • Isotonic Strength •Rhomboids •Wall push-ups Normal = No change p 10 reps

Serratus Ant. Strength Lower Trap Strength Test Test

Rhomboid Strength Rehabilitation Test

6 Rehabilitation Initial Rehabilitation Progression

Performance

Agility

Proprioception

Strength/Endurance Range of Motion/Flexibility Range of Motion/Flexibility

Inflammation & Rehab Proliferation & Rehab

1 2 3 12 3 • Limit Tissue Stress: – Fibrin plug is Primary Tissue Strength • Tissue Remains Weak but Improving • Avoid Early Exercise: with Collagen Production – Increases Stress to Fragile Tissue • Begin ROM with Mild Strengthening • Goals (Exception: Repairs) – Control Edema & Pain • Early Proprioception, Balance – Maintain C-V & Segment Function • Treatment: • Joint mobilization: I–III for Pain, ROM – Modalities for Edema & Pain • Big Difference Between Early & Late – Joint Mob: I, II for Pain

Remodeling & Rehab Soft Tissue Mobilization 1 2 3 • Assess & Treat soft tissue • Progressive Tensile Strength Increases Allows Concomitant restrictions Increases in Applied Stresses • Various soft tissue • Joint Mob: II – IV techniques • Be Aware of Excessive Stress – TP Indicators and Respond Accordingly – MFR – Massage – Strain-Counterstrain

7 AC Joint Mobilizations SC Joint Mobilizations

• AP glides • AP glides • PA glides • Superior • Inferior glides glides • Inferior glides

GH Joint Mobilization: GH Mob: Inferior Oscillation Glides

GH Mob: Posterior GH: Anterior Glides Glide

8 Scapulothoracic Mobs Scapulothoracic Mobs Inferior Glide Scapular Distractions

Joint Mob: Post Glide c Joint Mob: Ant Glide c Medial Rotation Lateral Rotation

Costovertebral Mobs Flexibility Codman’s: Passive motion only

9 Inferior Capsule Posterior Capsule Stretch Stretch

Superior Capsule Med. Rot. Stretch Stretch

Active G-H ROM Strength/Proprioception Exercises

Proprioception

Strength/Endurance

10 Shoulder Muscles Evidence-Based Exercises Strength & Endurance • Lower Trapezius

• Scapular Muscles • GH Muscles – Bouhler exercises in prone –Ekstrom et al, 2003

– Lower Trapezius – RC – Prone LR in 90° abd –Ekstrom et al, 2003

– Serratus Anterior – Large Movers – Row or Prone row –Ekstrom et al, 2003; Moseley et al, 1992

– Rhomboids & – Horizontal abduction c LR --Moseley et al, 1992; Middle Trapezius Ekstrom et al, 2003 – Push-up plus -- Moseley et al, 1992

Evidence-Based Exercises Evidence-Based Exercises

• Serratus Anterior • Rhomboids and Middle Trapezius – Upward rotation activities –Ekstrom et al, 2003; Moseley et al, 1992 – Prone Bouhlers –Ekstrom et al, 2003 – Bilateral scapular protraction –Ekstrom et al, 2003; Moseley et al, 1992; Decker et al, 1999 – Horizontal extension with LR –Ekstrom et al, 2003; Moseley et al, 1992 • Push-up plus -Moseley et al, 1992 – Row –Ekstrom et al, 2003; Moseley et al, 1992 • Dynamic hug -Decker et al, 1999 • Simultaneous SA and UT activity

– Bouhlers in prone –Ekstrom et al, 2003 – Shoulder abduction in scapular plane –Ekstrom et al, 2003

Evidence-Based Exercises Evidence-Based Exercises • for Shoulder Movers --Townsend et al, 1991 – Supraspinatus: • Deltoid • Pectoralis Major • Prone horizontal abduction in LR – Shoulder – Press-up --Blackburn et al, 1990 abduction – Push-up • Military press --Townsend et al, 1991 – Shoulder flexion • Scapular plane elevation --Townsend et al, 1991 • Latissimus Dorsi – Military press – Infraspinatus & Teres Minor: – Press-up – Row • Prone LR in 90° abduction & elbow flexion --Blackburn et al, 1990

• Lateral rotation --Townsend et al, 1991

11 Other Evidence-Based Info Scapular Taping

• Proprioceptors are damaged • For secondary impingement – Must be restored for function –Myers & Lephart, 2000 • Facilitates lower & middle trap and • Scapular stability must be inhibits upper trap --Morin et al, 1997 restored before scapular • Enhances muscle re-ed & scapula movement –Mottram, 1997 positioning with ↓ pain --Host, 1995; Lewis et al, 2005 • Scapula setting must be • MUST be accompanied c exercise established before activity –Mottram, 1997; Smith et al, 2002

Scapular Taping Early Exercises

• Open Kinetic Chain * JRS: Mimic Positions * Stabilizing Against Manual Resistance -Sidelying with manual resistance -Supine with isometric resistance

Early HEP: Isometrics Early HEP: Isometrics ABD MR

Joint Movers

Extensors LR Rotator Cuff Flexors

12 Manual Resistance Manual Resistance Sidelying with manual resistance Supine with isometric resistance

R. C. Resistance CKC Stabilization • Static *Quadruped with resistance *Tripod/Bipod with resistance • Low Level Dynamic: Swiss Ball *Legs on ball & *Arms on ball Increasingly Unstable Base Keep in Lower Ranges *Balance board: c & s Swiss Ball - Abduction to 30° -LR to 0° *Fitter: on knees, on feet, on bench - MR Starts at 0°

Rhythmic Stabilization Low Level on Swiss Ball

13 Quadruped Weight Tripod Weight Bearing Bearing

Biped Weight Bearing Rhythmic Stabilization

TB: Rotator Cuff TB: Rotator Cuff - L.R. Abduction

14 TB: Rotator Cuff - M.R. TB: Serratus Anterior

TB: Lower Trapezius TB: Rhomboids

Concentric/Eccentric Push-up: Early Progression • PNF & Manual • Eccentric Pushups Resistance – *Wall c & s – *Isometric, manual concentric, resistance eccentric – *On incline, on floor, on boxes

15 Push-up: Early Push-up: Early Progression Progression

Push-up: Early Push-up: Early Progression Progression

Other Scapular Scapular Strength: Concentric/Eccentrics Bouhlers • Bouhlers: Upward Rotators • Lower Trap Strengthening • Advanced Theraband Exercises • Seated Pushups: Shoulder girdle

16 Scapular Strength: Scapular Strength: Advanced Bouhlers Lower Trap

Straight-Plane Diagonal-Plane Elastic-Band Exercises Exercises

Diagonal-Plane Shoulder Girdle Exercises Strength Seated Push-up

17 Alphabet with Medicine Medicine Ball Ball Exercises • Quadruped Balance Activities • Stabilization at 90º Elevation in Supine • Seated Alphabet

Progressive Supine Eccentrics: Early Medicine Ball Exercises • Supine ER Drop Catches • Supine Toss: Progressive Throwing • Standing Eccentric IR & ER • Rebounder Activities

Upright Supine Eccentrics, Early Eccentric/Concentric Tosses: IR

18 Upright Machine Exercises Eccentric/Concentric Tosses: ER • Bench Press Plus: Controlled & Ballistic • Lower Trap on Lat Pull down unit • Flies: Reverse Flies & Rows • Seated Press Downs

Shoulder Girdle Strength Shoulder Girdle Strength Eccentric Bench Press Plus

Fly and Reverse Fly

Row

Other Upper Quarter Core Exercises Considerations • Early – Hip, Trunk, & Core Strength • Posture – Lower Abdominals Lumbar Posture • Later Cervical & Thoracic Posture – Medicine Ball Sit-ups • Core & Trunk Strength * Chest Passes Transverse abdom./Multifidus * Overhead & Rotational Passes Obliques & Rectus abdom/Quad Lumborum – Medicine Ball Twists • Hip Strength & Flexibility • Advanced – Abdominal Roller

19 Core Exercises Core Exercises

Core Exercises Core Exercises

Progression of Elevation Agility Exercises

• Start Below 60o Elevation • Advance to Mid-Range Elevation • Overhead Activities Occur Last Agility

20 Use Your Imagination Agility Exercises

• Isokinetics • Treadmill Walking • Wheelbarrow Exercises • Box Jumps

Think Outside the Box!!

Moderate Moderate Agility Agility/Coordination

Mod-Adv Agility Advanced Agility

21 Advanced Agility/Core Plyometric Push-Up Variations

Plyometrics Functional & Sport Specific Activities

Performance

Functional Activities Skill Agility Drills Requirements • Initially Controlled Conditions • Start at Short Distances • Advance as Confidence Increases • Start at Low Resistance • Full return parameters: • Start at Low Repetitions •Pain Free • Increase Only One •Full Motion Parameter at a time •Full Strength & Endurance • Increase Only ~ Every 3 •Sufficient Skill Acquisition Days

22 Functional/Sport- Summary Specific

Summary Summary • Understand mechanism & biomechanics • Justify all program aspects • Scapular Control is • Rehab Involves All Parameters established through • Core, Trunk, & Hip Exercises logical and justifiable progression & integration of Static & • Scapular Mobility, Stability, and Strength are Essential Elements Dynamic, OKC & CKC Exercises, Concentric & Eccentric, Plyometrics • Scapular Stabilization is Basic to Glenohumeral Function & Balance

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