Thomas A Goodwin DO Borgess Sports Medicine Kalamazoo, MI Discuss Discuss Discuss Scapular Discuss Rehabilitation Scapular Functional Scapular of Scapular Injuries Anatomy Mechanics Injuries Muscular Functional Fractures Joint Injury Injury Disturbance Direct and Scapular Indirect GH/labrum Rotator cuff Dyskinesis Clavicle, Muscular SICK ribs, etc AC detachment Scapula SC GIRD Kinetic Chain Influence Scapula, Clavicle, Ribs • Present in 1% of blunt trauma cases • 0.4-1% of all bone fractures • 80-90% with concomitant injuries • Clavicle fracture (23%) “Floating Shoulder” • Shoulder dislocation • Pulmonary Contusion/Pneumothoax (23%) • Also flail chest and tension pneumo • Brachial plexus • Axillary artery injury • Rib fractures • CT scan often required to determine severity http://www.wheelessonline.com/ortho/scapular_fractures • Site • Body/Neck • 2/3 of scapular fractures • Usually impacted and extraarticular • Good prognosis • Surgical Indications • > 1cm medial displacement • > 400 angulation • Glenoid Lip • Usually associated with dislocation • Surgery - > 10mm displacement or 25% intraarticular • Glenoid Fossa • Uncommon (< 10%). Surgery if > 5mm displacement http://www.wheelessonline.com/ortho/scapular_fractures • Alone • Disruption often leads to abnormal protraction of the scapula • Floating Shoulder1,2 • Concomitant Scapular fracture http://www.orthofracs.com/adult/trauma/shoulder/ • Scapular Suspensory System floating-shoulder.html • Superior(SSSS) • Lateral (LSSS) • Ribs • Often lead to dyskinesis 1. http://www.wheelessonline.com/ortho/floating_shoulder_injuries 2. Lambert S et al. Focussed classification of scapula fractures.Injury 2013. http://dx.doi.org/10.1016/j.injury.2103.03.001 Glenohumeral/labral, Acromioclavicular, Sternoclavicular • “Torn loose” vs “Born loose” • Multidirectional instability (MDI) • Labral Tear • Multidirectional instability (MDI) • Labral Tear AC injury SC injury Rotator Cuff, Muscle Detachment • Very Broad Term • Local Problems • RC, Long head biceps • Bursitis • Labral pathology • Impingement • Distant Problems • Rotator Cuff Tears • Scapular dyskinesis • Kinetic chain disruption • Chicken or the egg??? • Either way, treat the scapula! • Lower trap and rhomboids • Detach from medial scapular border • Uniform presentation • Early post-traumatic onset of localized intense pain along the medial scapular border • Major limitations in forward flexion or overhead Scapular Muscle • Localized tenderness Detachment • Palpable soft tissue defect • Altered scapular resting position • Dynamic dyskinesis • Positive SRT • MRI and CT not helpful • PT first but occasional surgery Scapular Dyskinesis/GIRD/Upper Crossed Syndrome • Upward/Downward Rotation • Internal/External Rotation Scapular Motions • Anterior/Posterior Tilt In isolation, these are • Upward/Downward Glide clinically limited • External Rotation • Posterior Tilt Retraction • Upward Rotation • Medial Translation • Internal Rotation Protraction • Anterior Tilt Clinical Implications • Downward Rotation Composite, Coupled • Lateral Translation Motion • Upward Translation Shrug • Anterior Tilt • Internal Rotation • Kibler 2001 • “An observable alteration of the position and motion of the scapula relative to the thoracic cage • “The requirement of high levels of scapular muscle activation to stabilize the scapulothoracic aritculation and optimally position the glenoid to maximize glenohumeral congruity” • Scapular malposition • Inferior medial border prominence • Coracoid pain • Dyskinesis • Tight pec minor/biceps • Lowered throwing shoulder • > 20o • Tight posterior capsule • PIGHL • Leads to “Wind-up” • Increased protraction • Kinetic chain disruption Swimming: Dyskinesis/GIRD? Strength Program 1 1 Calders P, et al. Scapular-muscle performance: two training programs in adolescent swimmers. J Ath Training. 2011. 46.2:160-72 Throwing Athletes Overhead Athletes: Dyskinesis/GIRD? Kinetic Chain Influence • Follow through Increased anterior tilt and IR • Eccentric strengthening Rogowski I, et al. Scapulothoracic kinematics during tennis forehand drive. Sports Biomechanics 2014. 13(2), 166-175) Determine Identify abnormal relations between Identify causative scapular motion dyskinesis and factors for symptoms dyskinesis Evaluate for Evaluate “tightness” muscle Postural Evaluate • Posterior strength Evaluate the evaluation dyskinesis capsule • Scapular kinetic chain • Pec minor Stabilizer Muscle Testing • Serratus Anterior • Upper Trapezius • Middle/Lower Trapezius Kibler BW et al. Clinical applications of scapular dyskinesis in shoulder injury: The 2013 consensus statement from the scapular summit. BJSM 2013. 092045 Tsun-Shun H et al. Specific kinematics and associated muscle activation in individuals with scapular dyskinesis. J Shoulder and Elbow Surg. 2015 Struyf F et al. Scapulothoracic muscle activity and recruitment timing in patients with shoulder impingment symptoms and glenohumeral instability. J Electromyography and Kinesiology. 2014. 24: 277-284 • Forward head posture • Increased thoracic kyphosis • Shortened pectoralis minor • Posterior shoulder tightness • Upper Crossed Syndrome evaluation • Pec Minor • Posterior Capsule • PIGHL • Lateral Scapular LST Slide Test • Scapular SAT Assistance Test Dynamic Scapular Dyskinesis Tests • Scapular SRT Retraction Test • Static Measurement • Inf angle Scapula Spinous Process • Validity questioned2 • Unable to differentiate between symptomatic and asymptomatic shoulders 1Kibler WB et al. The role of the scapula in athletic shoulder function. AJSM 1998; 22:325-7 2Nijs J et al. Scapular positioning in patients with shoulder pain. Arch Phys Med Rehabil 2005;86:1349-55 Reduction or abolition of pain = positive Rabin A et al. The intertester reliability of the Scapular Assistance Test. J Orthop Sports Phys Ther 2006;36:653-60 Increased strength = positive Tate A et al. Effect of the scapula reposition test on shoulder impingement symptoms and elevation strength in overhead athletes. J Orthop Spor Phys Ther 2008;38:4-11 Nijs J et al. Scapular positioning in patients with shoulder pain. Arch Phys Med Rehabil 2005;86:1349-55 Type I Type II Type III Kibler WB, Uhl TL, Jackson JW, Brooks PV, Zeller B, McMullen J: Qualitative clinical evaluation of scapular dysfunction: A reliability study. J Shoulder Elbow Surg 2002;11:516-27. • Laboratory studies with 3D tracking1-5 • Gold Standard • Practicality? 1Bourne et al. Three dimensional rotation of the scapula during functional movements. J Shoulder Elbow Surg. 2007;16:150-162 2Konda et al. Scapular rotation to attain the peak shoulder external rotation in tennis serve. Med Sci Sports Exerc. 2010;42:1745-1753 3McClure et al. Direct 3-dimensional measurement of scapular kinematics J Shoulder Elbow Surg. 2001;10:269-277 4Uhl et al. Evaluation of clinical assessment methods for scpular dyskinesis. Arthroscopy. 2009;25:1240-1248 5Ellenbecker et al. Reliability of scapular classification in examination of professional baseball players. Clin Ortho Relat Res. 2012. 470:1540-44 SAT and SRT Inter-rater are most diagnostic reliable 1 tests3 reliability Dyskinesis best assessed in lowering phase1,2 1Haung TS et al. Comprensive classification test of scapular dyskinesis: A reliability study. Manual therapy 2014:1-6 2Haung TS et al. Specific kinematics and associated muscle activation in individuals with scapular dyskinesis. J Shoulder Elbow Surg. 2015:1-8 3 Struyf F et al. Clinical assessment of the scapula: A review of the literature. BMJ 2014;48:883-890 Evaluation • Core • Planks • Single leg squat • Muscle recruitment patterns • Hip flexor/Rectus femoris tension Identify causative factors Neurologic Joint Bone* Inflexibility Muscular Kinetic Chain • Nerve Palsy Derangement* • Clavicle fractures • GIRD • Lower trap • Hip/leg (long • Labral injury • Scapular • Total ROM weakness weakness thoracic/spinal fractures deficits • Serratus anterior • Core weakness accessory) • GH instability • Biceps tendinitis • Pec minor weakess inflexibility • Upper trap • AC separation hyperactivity • Scapular muscle detachment *- May need surgical correction before appropriate rehab can begin Activation Forced Couple Concentric/Eccentric Sequencing Activation Emphasis Avoidance of Strength Endurance Unwanted Patterns Reacquisition Scapula must Sports specific of muscle and be in retracted rehab patterns joint flexibility position • Diagonal • Capsule • Ratios • KC sequencing Kinetic chain, stretches, exercises, manual therapy • Slight variations = better results • Knee pushup plus (KPP)1 and forward punch plus (FPP)2 showed differing degrees of SA activation with variation 1Maenhout et al. EMG analysis of knee pushup plus variations. BJSM 2010;44:1010-15 2Kaur et al. Effects of lower extremity and trunk muscle recruitment on serratus anterior muscles activation. Int J Sports PT 2014;9(7):924-937 • Sleeper stretch • Cross body stretch • Increase AH distance4 1Ellenbecker and Cools. Rehabilitation of shoulder impingement syndrome and rotator cuff injuries: an evidence-based review Br J Sports Med 2010;44:319–327. 2Cools et al. Stretching the posterior shoulder structures in subjects with internal rotation deficit. Shoulder and Elbow 2012 4:56-63 3Manske et al. A randomized controlled single-blinded comparision of stretching and joint mobilization for posterior shoulder tightness. Sports PT 2010. 94-100 4Maenhout A et al. Quantifying acromiohumeral distance in over head athletes . AJSM 2012;40(9):2105-2115 Scapular Wall Inferior Clock Washers Glide Lawn The Low Row Mower Robbery EMG Studies: