Scapular dyskinesia and its relationship to rotator cuff impingement syndrome

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  • Muscles of the shoulder girdle??Trap attachments?
  • Upward Rotators-UFT/LFT + Serr are the greatest contributors to scapular stability and mobility (Kibler, 2012, p 365)-
  • Downward Rotators
  • due to weak scapular/RC muscules
  • (sensitivity, 78% [arm flexion] and74% [scaption]; positive predictivevalue, 76% [arm flexion] and 78%[scaption])
  • the examiner appliesgentle pressure to push on the inferiormedial scapular angle to assistscapular upward rotation and posteriortilt as the patient elevates thearm
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  • Kibler WB, McMullen J: Scapular dyskinesis and its relation to shoulder pain. J Am AcadOrthop Surg.2003;11:142-151.
  • Scapular dyskinesia and its relationship to rotator cuff impingement syndrome

    1. 1. + Scapular Dyskinesia and its Relationship to Rotator Cuff Impingement Syndrome Nadir Mawji MSc PT Student Year 2 May 16, 2013
    2. 2. +
    3. 3. +
    4. 4. +
    5. 5. + Scapulohumeral Rhythm
    6. 6. +
    7. 7. +
    8. 8. +
    9. 9. +
    10. 10. + Why Supraspinatus?
    11. 11. + Rotator Cuff Impingement Treatment Best Practice  Key messages from Kuhn, 2009:  Exercise is effective as a treatment to reduce pain  Exercise + manual therapy = best outcomes  The literature is not clear on which exercises are best, but must be addressed to individual patient needs (clinical reasoning)
    12. 12. + Impingement Syndrome Exercises (Kuhn, 2009)
    13. 13. + Impingement Syndrome Exercises (Kuhn, 2009)
    14. 14. +
    15. 15. +
    16. 16. + What is Scapular Dyskinesia?  “Alteration in the normal static or dynamic position or motion of the scapula during coupled scapulohumeral movements.” (Sevinsky, S)  Alters the scapulohumeral rhythm  Scapular dyskinesis identified in (Warner, 1992):  68% of RC problems  100% of GH instability
    17. 17. + Less Common Causes of Scapular Dyskinesia  Bony  thoracic kyphosis, clavicular # (non-union), shortened clavicular malunion  Joint  High grade AC instability, AC arthrosis/instability, GH jt internal derangement  Neurologic  Cervical radiculopathy, nerve palsy (long thoracic n, spinal acc n) (Kibler, 2012)
    18. 18. +
    19. 19. +Common Causes of Scapular Dyskinesia 1. Shortening of pec minor, short head of biceps brachii  Result in anterior tilt + protraction of scapula 2. GH IR deficit Creates “windup” of scapula on thorax with arm in IR or ABD (Kibler, 2012)
    20. 20. + 3. Poor Patterning -Serratus activation/strength -loss of posterior tilt/upward rotation -Altered UFT/LFT Force couple -delayed onset of LFT alters upward rotation and reduces posterior tilt (Kibler, 2012) Common Causes of Scapular Dyskinesia
    21. 21. + Identification of Scapular Dyskinesia Observation: SICK posture (Burkhart, 2003)  Scapular malposition  Inferior medial border prominence  Coracoid pain and malposition  Dyskinesis of scapular movement
    22. 22. + Clinical Examination Findings Dynamic Examination of Flexion/Abd -Pt holds 3-5 lb weight -observe repeated flexion/abd 4- 5 times -prominence of medial border suggestive of scapular dyskinesia sensitivity, 78% [flexion] 74% [scaption] positive predictive value, 76% [flexion] 78% [scaption] (Kibler, 2003)
    23. 23. + Scapular Assistance Test  Used in evaluating scapular contributions to impingement and RC strength
    24. 24. + Test Time!
    25. 25. + Inferior Glide Exercise (LFT)
    26. 26. + Low Row (LFT)
    27. 27. + Push “Plus” (Serr Ant)
    28. 28. + Lawn Mower (LFT progression)
    29. 29. + Robbery (LFT Progression)
    30. 30. + Summary  Determine if scapular dyskinesia is present  Observe for SICK scapula  Dynamic testing (look for prominent inferior/medial border)  Apply corrective movement and assess for change  If Scapular dyskinesia is present  Address underlying dysfunction  Stretch short pec minor/short head of biceps  Manual therapy to reduce GH IR deficit  LFT/Serr strengthening for poor patterning
    31. 31. (Kibler, 2003)
    32. 32. + References 1. Kibler WB, Sciascia AD, Uhl TL, Tambay N, Cunningham T. Electromyographic Analysis of Specific Exercises for Scapular Control in Early Phases of Shoulder Rehabilitation. Am J Sports Med. 2008 Sep 1;36(9):1789–98. 2. Kuhn JE. Exercise in the treatment of rotator cuff impingement: a systematic review and a synthesized evidence-based rehabilitation protocol. J Shoulder Elbow Surg. 2009 Feb;18(1):138–60. 3. Tyler TF, Nicholas SJ, Roy T, Gleim GW. Quantification of posterior capsule tightness and motion loss in patients with shoulder impingement. The American journal of sports medicine. 2000;28(5):668– 73. 4. Kibler WB, Sciascia A, Wilkes T. Scapular dyskinesis and its relation to shoulder injury. Journal of the American Academy of Orthopaedic Surgeons. 2012;20(6):364–72. 5. Kibler WB, McMullen J. Scapular dyskinesis and its relation to shoulder pain. J Am Acad Orthop Surg. 2003 Apr;11(2):142–51. 6. Warner JJ, Micheli LJ, Arslanian LE, Kennedy J, Kennedy R. Scapulothoracic motion in normal shoulders and shoulders with glenohumeral instability and impingement syndrome A study using Moire topographic analysis. Clinical orthopaedics and related research. 1992;285:191–9. 7. Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology Part III: The SICK scapula, scapular dyskinesis, the kinetic chain, and rehabilitation. Arthroscopy. 2003;19(6):641–61. 8. Parsons IM, Apreleva M, Fu FH, Woo SLY. The effect of rotator cuff tears on reaction forces at the glenohumeral joint. J. Orthop. Res. 2002 May;20(3):439–46. 9. Kibler WB. The role of the scapula in athletic shoulder function. The American Journal of Sports Medicine. 1998;26(2):325–37.

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