11. +
Rotator Cuff Impingement
Treatment Best Practice
๏ฎ Key messages from Kuhn, 2009:
๏ฎ Exercise is effective as a treatment to reduce pain
๏ฎ Exercise + manual therapy = best outcomes
๏ฎ The literature is not clear on which exercises are best, but must be
addressed to individual patient needs (clinical reasoning)
16. +
What is Scapular Dyskinesia?
๏ฎ โAlteration in the normal static or dynamic position or motion of
the scapula during coupled scapulohumeral movements.โ
(Sevinsky, S)
๏ฎ Alters the scapulohumeral rhythm
๏ฎ Scapular dyskinesis identified in (Warner, 1992):
๏ฎ 68% of RC problems
๏ฎ 100% of GH instability
17. +
Less Common Causes of Scapular
Dyskinesia
๏ฎ Bony
๏ฎ thoracic kyphosis, clavicular # (non-union), shortened clavicular
malunion
๏ฎ Joint
๏ฎ High grade AC instability, AC arthrosis/instability, GH jt internal
derangement
๏ฎ Neurologic
๏ฎ Cervical radiculopathy, nerve palsy (long thoracic n, spinal acc n)
(Kibler, 2012)
19. +Common Causes of Scapular Dyskinesia
1. Shortening of pec
minor, short head of biceps
brachii
๏ฎ Result in anterior tilt +
protraction of scapula
2. GH IR deficit
Creates โwindupโ of
scapula on thorax with arm
in IR or ABD
(Kibler, 2012)
20. +
3. Poor Patterning
-๏ชSerratus 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. +
Identification of Scapular Dyskinesia
Observation: SICK posture (Burkhart, 2003)
๏ฎ Scapular malposition
๏ฎ Inferior medial border prominence
๏ฎ Coracoid pain and malposition
๏ฎ Dyskinesis of scapular movement
30. +
Summary
๏ฎ Determine if scapular dyskinesia is present
๏ฎ Observe for SICK scapula
๏ฎ Dynamic testing (look for prominent inferior/medial border)
๏ฎ Apply corrective movement and assess for change
๏ฎ If Scapular dyskinesia is present
๏ฎ Address underlying dysfunction
๏ฎ Stretch short pec minor/short head of biceps
๏ฎ Manual therapy to reduce GH IR deficit
๏ฎ LFT/Serr strengthening for poor patterning
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):1789โ98.
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):138โ60.
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):668โ
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):364โ72.
5. Kibler WB, McMullen J. Scapular dyskinesis and its relation to shoulder pain. J Am Acad Orthop
Surg. 2003 Apr;11(2):142โ51.
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;285:191โ9.
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):641โ61.
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):439โ46.
9. Kibler WB. The role of the scapula in athletic shoulder function. The American Journal of Sports
Medicine. 1998;26(2):325โ37.
Editor's Notes
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)-
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.