Scapular Dyskinesia: Difference between revisions

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== Management / Interventions<br>  ==
== Management / Interventions<br>  ==


Intervention is aimed at reducing posterior capsule(46) and pectoralis minor restriction(53) and restoring periscapular mm balance through exercises promoting early and increased serratus anterior, lower, and middle trapezius activation while minimizing upper trapezius activity(41).&nbsp; <br>  
Intervention is aimed at reducing posterior capsule<ref name="McClure2">McClure P et al.A randomized controlled comparison of stretching procedures for posterior shoulder tightness.JOSPT.2007;37:108-114.</ref> and pectoralis minor restriction<ref name="Muraki">Muraki T et al.Lengthening of the pectoralis minor muscle during passive shoulder motions and stretching techniques: a cadaveric biomechanical study.Phys Ther.2009;89:333-341.</ref> and restoring periscapular mm balance through exercises promoting early and increased serratus anterior, lower, and middle trapezius activation while minimizing upper trapezius activity.<ref name="Ludewig2">Ludewig PM et al. Relative balance of serratus anterior and upper trapezius muscle activity during push-up exercises.Am J Sports Med.2004;32:484-493.</ref>&nbsp; <br>  


*&nbsp;&nbsp;&nbsp;&nbsp; Manual gr 4 mobilization to reduce posterior capsule tension, cross-body stretch (46).<br>  
*&nbsp;&nbsp;&nbsp;&nbsp; Manual gr 4 mobilization to reduce posterior capsule tension, cross-body stretch.<ref name="McClure2" /><br>  
*&nbsp;&nbsp;&nbsp;&nbsp; Manual stretching and soft tissue mobilization to decrease pec minor tension (cadaveric studies imply that a position of 150 degrees elevation with 30 degrees scapular retraction is optimal). (53)<br>  
*&nbsp;&nbsp;&nbsp;&nbsp; Manual stretching and soft tissue mobilization to decrease pec minor tension (cadaveric studies imply that a position of 150 degrees elevation with 30 degrees scapular retraction is optimal).<ref name="Muraki" /> <br>  
*&nbsp;&nbsp;&nbsp;&nbsp; Exercises of sidelying forward flexion, external rotation, prone extension, and prone horizontal abduction to strengthen middle and lower trapezius over upper trapezius. (17)(19)<br>  
*&nbsp;&nbsp;&nbsp;&nbsp; Exercises of sidelying forward flexion, external rotation, prone extension, and prone horizontal abduction to strengthen middle and lower trapezius over upper trapezius.<ref name="Cools">Cools AM et al. Rehabilitation of scapular muscle balance: which exercises to prescribe? Am J Sports Med.2007;35:1744-1751.</ref>,<ref name="deMey">de Mey K et al. Trapezius muscle timing during selected shoulder rehabilitation exercises.JOSPT.2009;39:743-752.</ref> <br>  
*&nbsp;&nbsp;&nbsp;&nbsp; Quadruped and variable push-up positions to activate serratus anterior (41).
*&nbsp;&nbsp;&nbsp;&nbsp; Quadruped and variable push-up positions to activate serratus anterior.<ref name="Ludewig2" />


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== Key Evidence  ==
== Key Evidence  ==

Revision as of 05:47, 2 December 2009

Original Editor - Jon DeVaul, PT, DPT

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Clinically Relevant Anatomy
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Typical movement of the scapula occurs in the sagital, coronal, and transverse planes. The primary movements consist of two translations: superior/inferior, and protraction/ retraction, as well as three rotations: upward/downward, internal/external, and anterior/posterior. Upward rotation is primary and posterior tilt secondary during normal overhead UE elevation with internal/external rotation being minimal until 100°. [1],[2]

Review of the normal ratio of glenohumeral (GH) to scapulothoracic (ST) motion analyzed by Doody et al[3] under three-dimensional analysis found that the ratio of GH to ST motion changes from 7.3: 1 in the first 30° of elevation to 0.78: 1 between 90 and 150°. Bagg and Forrest found a ratio of 4.4:1 during early phase, and 1.7:1 within 80 to 140° of shoulder elevation.[4]

Clinical Presentation[edit | edit source]

Kibler classification of scapular dysfunction. [5]

  1. Type I or Inferior dysfunction.  The primary external visual feature is the prominence of the inferior angle as a result of anterior tilting of the scapula in the sagital plane. Inferior pattern presentation is better visualized while in the hands-on-hips position or during eccentric lowering from overhead elevation, scaption, or abduction. According to Kibler, Type 1 pattern is most commonly found in patients with rotator cuff dysfunction.
  2. Type 2 or Medial dysfunction.  The primary external visual feature is the prominence of the entire medial scapular border due to internal rotation of the scapula in the transverse plane. As with Type 1, the Type 2 presentation becomes more evident in the hands-on-hips position and during active eccentric lowering from overhead. Medial pattern dysfunction most often occurs in patients with glenohumeral joint instability.
  3. Type 3 or Superior dysfunction.  Characterized by excessive and early elevation of the scapula during UE elevation. This pattern has been referred to as compensatory shoulder hiking or shrug and is most often seen in patients with rotator cuff dysfunction and deltoid-rotator cuff force couple imbalances.[6]

Diagnostic Procedures[edit | edit source]

Current tests and measures, while proven to be reliable, have not altogether shown strong validity by demonstrating correlation with biomechanical motion, symptoms, pathology, or outcomes.[7] Recommendations for appropriate clinical measures include:

  • Clinical observation of scapular dyskinesis.

             Kibler classification of dysfunction Type 1, 2, or 3.  It is recommended that several repeated bouts of arm elevation be observed to assess the affects of fatigue on scapular stabilization.

  • Symptom altering tests.

             Scapular reposition test.[8] Baseline AROM and pain is evaluated.  This test is positive if pain is reduced as the therapist assists active elevation by applying a posterior tilt and external rotation motion to the scapula. This application may be used in conjunction with other tests such as Neer's, Hawkin's-Kennedy, and Jobe's relocation.

Level of evidence: 4.

             Scapular assistance test.[9] Baseline AROM and pain is evaluated.  The therapist then applies an assist to scapular dynamics.  This test is positive if ROM is increased or pain is reduced as the therapist manually assists scapular upward rotation during active UE elevation.  

  • Manual muscle testing.

              MMT for the middle and lower trapezius, and serratus anterior.

  • Pectoralis minor muscle tightness.

              Current measures examine mm length at resting positions, not at maximal length.  Unfortunately, there are no validated clinical measures to identify a patient as having a tight pectoralis minor muscle.   

Outcome Measures[edit | edit source]

http://www.dash.iwh.on.ca/assets/images/pdfs/quickdash_q06.pdf

Management / Interventions
[edit | edit source]

Intervention is aimed at reducing posterior capsule[10] and pectoralis minor restriction[11] and restoring periscapular mm balance through exercises promoting early and increased serratus anterior, lower, and middle trapezius activation while minimizing upper trapezius activity.[12] 

  •      Manual gr 4 mobilization to reduce posterior capsule tension, cross-body stretch.[10]
  •      Manual stretching and soft tissue mobilization to decrease pec minor tension (cadaveric studies imply that a position of 150 degrees elevation with 30 degrees scapular retraction is optimal).[11]
  •      Exercises of sidelying forward flexion, external rotation, prone extension, and prone horizontal abduction to strengthen middle and lower trapezius over upper trapezius.[13],[14]
  •      Quadruped and variable push-up positions to activate serratus anterior.[12]


Key Evidence[edit | edit source]

Unfortunately, scapular dyskinesia is a condition with minimal level 1 evidence for support of either diagnosis or treatment.  Support for above mentioned tests and interventions appears below.

Resources
[edit | edit source]

Orthopaedic Physical Therapy by Donatelli and Wooden, Fourth Edition.

JOSPT

References[edit | edit source]

References will automatically be added here, see adding references tutorial.

  1. ↑ Ludewig PM et al. Motion of the shoulder complex during multiplaner humeral elevation. J Bone Joint Surg. Am.2009;91:378-389.
  2. ↑ McClure PW et al. Direct 3-dimentional measurement of scapular kinematics during dynamic movements in vivo.J Shoulder Elbow Surg.2001:10:269-277.
  3. ↑ Doody SG et al.Shoulder movements during abduction in the scapular plane.Arch Phys Med Rehab.1970:595-604.
  4. ↑ Bagg SD, Forrest Wj. A biomechanical analysis of scapular rotation during arm abduction in the scapular plane.Arch Phys Med Rehabil.1988:238-245.
  5. ↑ Kibler WB et al.Qualitative clinical evaluation of scapular dysfunction: a reliability study. J Shoulder Elbow Surg.2002;11:550-556.
  6. ↑ Inman VT et al.Observation on the function of the shoulder joint.J Bone Joint Surg.1944;26:1-30.
  7. ↑ Kuhn JE.Physical examination of the scapula -a systematic review.JOSPT.2009;39:A11.
  8. ↑ Tate AR et al. Effect of the scapular repositioning test on shoulder impingement symptoms and elevation strength in overhead athletes.JOSPT.2008;38:4-11.
  9. ↑ Rabin et al. The intertester reliability of the scapular assistance test.JOSPT.2006;36:653-660.
  10. ↑ 10.0 10.1 McClure P et al.A randomized controlled comparison of stretching procedures for posterior shoulder tightness.JOSPT.2007;37:108-114.
  11. ↑ 11.0 11.1 Muraki T et al.Lengthening of the pectoralis minor muscle during passive shoulder motions and stretching techniques: a cadaveric biomechanical study.Phys Ther.2009;89:333-341.
  12. ↑ 12.0 12.1 Ludewig PM et al. Relative balance of serratus anterior and upper trapezius muscle activity during push-up exercises.Am J Sports Med.2004;32:484-493.
  13. ↑ Cools AM et al. Rehabilitation of scapular muscle balance: which exercises to prescribe? Am J Sports Med.2007;35:1744-1751.
  14. ↑ de Mey K et al. Trapezius muscle timing during selected shoulder rehabilitation exercises.JOSPT.2009;39:743-752.
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