10-2-13 945am Diagnosis and Treament of Scapular Injuries T_ Goodwin.pdf
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Thomas A Goodwin DO Borgess Sports Medicine Kalamazoo, MI
Transcript of 10-2-13 945am Diagnosis and Treament of Scapular Injuries T_ Goodwin.pdf
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Thomas A Goodwin DO
Borgess Sports Medicine
Kalamazoo, MI
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DiscussScapularInjuries
DiscussScapular
Functional Anatomy
DiscussScapular
Mechanics
DiscussRehabilitationof Scapular
Injuries
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Fractures
Direct andIndirect
Clavicle,ribs, etc
Joint Injury
GH/labrum
AC
SC
MuscularInjury
Rotator cuff
Musculardetachment
FunctionalDisturbance
ScapularDyskinesis
SICKScapula
GIRD
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Scapula, Clavicle, Ribs
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• 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
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• 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
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• Alone
• Disruption often leads to
abnormal protraction of the
scapula
• Floating Shoulder 1,2
• Concomitant Scapular
fracture
• Scapular Suspensory System
• Superior(SSSS)
• Lateral (LSSS)
• Ribs
• Often lead to dyskinesis
1. http://www.wheelessonline.com/ortho/floating_shoulder_injuries2. Lambert S et al. Focussed classification of scapula fractures.Injury 2013. http://dx.doi.org/10.1016/j.injury.2103.03.001
http://www.orthofracs.com/adult/trauma/shoul
der/floating-shoulder.html
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Glenohumeral/labral, Acromioclavicular, Sternoclavicular
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• Multidirectional
instability (MDI)
• Labral Tear
• 15/85
• “Torn loose” vs “Born loose”
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• Multidirectional
instability (MDI)
• Labral Tear
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AC injury
SC injury
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Rotator Cuff, Muscle Detachment
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• Very Broad Term
• Local Problems
• RC, Long head biceps
• Bursitis
• Labral pathology
• Distant Problems• Scapular dyskinesis
• Kinetic chain disruption
• Chicken or the egg???• Either way, treat the scapula!
• Impingement
• Rotator Cuff Tears
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• Lower trap and rhomboids• Detach from medial scapularborder
• Uniform presentation• Early post-traumatic onset of
localized intense pain along themedial scapular border
• Major limitations in forward flexion
or overhead• Localized tenderness• Palpable soft tissue defect
• Altered scapular resting position• Dynamic dyskinesis
• Positive SRT
• MRI CT not helpful
• PT first but occasional surgery
Scapular Muscle
Detachment
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Scapular Dyskinesis/GIRD/Upper Crossed Syndrome
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• Upward/Downward
Rotation
• Internal/External Rotation
• Anterior/Posterior Tilt
• Upward/Downward Glide
Scapular Motions
In isolation, these are
clinically limited
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• External Rotation
• Posterior Tilt
• Upward Rotation
• Medial Translation
Retraction
• Internal Rotation
• Anterior Tilt
• Downward Rotation
• Lateral TranslationProtraction
• Upward Translation• Anterior Tilt
• Internal RotationShrug
Clinical Implications
Composite, Coupled
Motion
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• Kibler 2001
• “An observable alterationof the position and motion of the scapula relative to
the thoracic cage• “The requirement of high
levels of scapular muscleactivation to stabilize thescapulothoracic
aritculation and optimallyposition the glenoid tomaximize glenohumeralcongruity”
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• Scapular malposition
• Inferior medial border
prominence
• Coracoid pain
• Dyskinesis
• Tight pec minor/biceps
• Lowered throwingshoulder
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• > 20o
• Tight posterior
capsule
• PIGHL
• Leads to “Wind-up”
• Increased protraction
• Kinetic chain disruption
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Swimming:
Dyskinesis/GIRD?
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Throwing Athletes
Overhead Athletes:
Dyskinesis/GIRD?
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Identify Abnormalscapular motion
Determinerelations between
dyskinesis andsymptoms
Identify causativefactors fordyskinesis
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• Evaluate Dyskinesis
• Examine Surrounding Tissues
• Scapular Stabilizer Muscle Testing
• Posture
• Muscle “tightness” evaluation
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• Forward head posture
• Increased thoracic
kyphosis
• Shortened pectoralisminor
• Posterior shoulder
tightness
• Upper Crossed
Syndrome evaluation
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• Pec Minor
• Posterior Capsule• PIGHL
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Dynamic Scapular
Dyskinesis Tests
LST• Lateral Scapular
Slide Test
SAT
• Scapular
Assistance Test
SRT
• Scapular
Retraction Test
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• Static Measurement
• ILA Scapula
Spinous Process
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Reduction or
abolition of pain =
positive
http://www.youtube.com/watch?v=I9Dzze57EWM
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http://www.youtube.com/watch?v=Tm_q2ipA0_o
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Type I Type II Type III
Kibler WB, Uhl TL, Jackson JW, Brooks PV, Zeller B, McMullen J: Qualitative clinical evaluation ofscapular dysfunction: A reliability study. J Shoulder Elbow Surg 2002;11:516-27.
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• Laboratory studies with
3D tracking1,2,3
• Gold Standard
• Practicality?• Clinical inter-rater
reliability questioned 3,5
• Conflicting evidence
1Bourne et al. Three dimensional rotation of the scapula during functional movements. J Shoulder Elbow Surg. 2007;16:150-1622Konda et al. Scapular rotation to attain the peak shoulder external rotation in tennis serve. Med Sci Sports Exerc. 2010;42:1745-17533McClure et al. Direct 3-dimensional measurement of scapular kinematics J Shoulder Elbow Surg. 2001;10:269-2774
Uhl et al. Evaluation of clinical assessment methods for scpular dyskinesis. Arthroscopy. 2009;25:1240-12485Ellenbecker et al. Reliability of scapular classification in examination of professional baseball players. Clin Ortho Relat Res. 2012. 470:1540-44
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• LST- Lateral Scapular
Slide Test
• Validity questioned• Unable to differentiate
between symptomatic
and asymptomatic
shoulders
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• SRT – ScapularRetraction Test
• Validityquestioned byKibler et al2006 (AJSM)• Found
increasedstrength
regardless ofsymptoms
http://www.youtube.com/watch?v=Tm_q2ipA0_o
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Evaluation
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• Core
• Planks
• Single leg squat
• Muscle recruitmentpatterns
• Hip flexor/Rectus
femoris tension
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Identify causative factors
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Neurologic•Nerve Palsy (longthoracic/spinalaccessory)
JointDerangement*
•Labral injury
•GH instability
•Biceps tendinitis
• AC separation
Bone*•Clavicle fractures
•Scapular fractures
Inflexibility•GIRD
•Total ROM deficits
•Pec minorinflexibility
Muscular•Lower trapweakness
•Serratus anteriorweakess
•Upper traphyperactivity
•Scapular muscledetachment
Kinetic Chain•Hip/leg weakness
•Core weakness
*- May need surgical correction before appropriate rehab can begin
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ActivationSequencing
Forced Couple Activation
Concentric/EccentricEmphasis
Strength Endurance Avoidance of
Unwanted Patterns
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ScapularClock
WallWashers
InferiorGlide
LowRow
LawnMower
TheRobbery
SleeperStretch
1Kibler et al. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. Am
J Sports Med 2008;36:1789 –98.
Forthomme B, Crielaard JM, Croisier JL. Scapular positioning in athlete's shoulder : particularities, clinical measurements and
im lications. S orts Medicine. 2008 38 5 :369-86.
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• Goal is to maximize
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• Goal is to maximize
MT/LT/SA and minimize
upper trap• Cools1 De Mey2 protocols
• Change activation patterns
• Validated by De Mey3
2012• Mild impingement syndrome
• 6 week home rehabilitation
• Significant reduction in painwith exercise alone
Which Exercises?
1Cools AM et al. Rehabilitation of scapular muscle balance: which exercise to prescribe? AJSM 2007;35(10):1744-17512De Mey K et al. Trapezius muscle timing during selected shoulder rehabilitation exercises. JOSPT 2009;39(10):743-752
3De Mey et al. Scapular muscle rehabilitation exercises in overhead athletes with impingement syndromes. AJSM 2012;40(8):1906-1915
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• Intuitively it makes sense
• Evidence?
• Sucher 1 found correction of pec minor shortening
• US Measurement
• Case study
• Rosa2 et al found no effect of manipulation on scapular
rhythm
• EMG study
• Asymptomatic patients
• Seated HVLA
1Sucher. Ultrasound-guided OMT for a patient with thoracic outlet syndrome. JAOA. 2011;111:543-547
2Rosa et al. Effect of seated thoracic manipulation on changes in scapular kinematics. J Manipulative Physio ther. 2013;Sep 5. epub
7/21/2019 10-2-13 945am Diagnosis and Treament of Scapular Injuries T_ Goodwin.pdf
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Dyskinesis presentin high percentageof shoulder injuries
Exact role ofdyskineis unknown
• Create or exacerbate?
Shoulderimpingement
particularly affectedby dyskinesis
Dyskinesis viewedas potential
impairment toshoulder function
Recognition ofdyskinesis
improves treatmentoutcome
Reliable clinicalevaluation method
for dyskinesiaexists
Rehab programsshould encompass
correction ofdyskinesis
7/21/2019 10-2-13 945am Diagnosis and Treament of Scapular Injuries T_ Goodwin.pdf
http://slidepdf.com/reader/full/10-2-13-945am-diagnosis-and-treament-of-scapular-injuries-t-goodwinpdf 68/68
