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Not to be reproduced without permission WPTA 4/21/2017
Sylvia Czuppon PT, DPT, OCS 1
Program in Physical Therapy
Diagnosis & Treatment of Cervical and Shoulder Dysfunction:
Movement System Impairment Syndromes (MSI)
Shirley Sahrmann, PhD, PT, FAPTA and Associates
Presented by: Sylvia Czuppon, PT, DPT, OCS
Associate Professor
Physical Therapy and Orthopaedic Surgery
Twitter: @czuppons
Email: [email protected]
Program in Physical Therapy
Statement of Privacy
• To protect the privacy of the subjects or patients that are depicted in this presentation and based on copyright laws, this information should not be shared in any manner. We do NOT allow any photographing or videotaping during any part of this presentation.
• Thank you for your cooperation.
Program in Physical Therapy
Missing Figures
•Any missing figures were intentionally omitted due to copyright laws in the United States.
Program in Physical Therapy
Associates – Washington University School of Medicine FacultyClinical Emphasis
Nancy Bloom, PT, DPT, MSOT Cheryl Caldwell, PT, DPT, CHT
Suzy Cornbleet, PT, DPT
Sylvia Czuppon, PT, DPT, OCS
Ryan DeGeeter, PT, DPT, SCS, CSCSJudy Gelber, PT, DPT, OCS, CSCS
Greg Holtzman, PT, DPT,SCS
Renee Ivens, PT, DPT
Lynnette Khoo-Summers, PT, DPTCaitlin Kothe, PT, DPT, MS
Vanessa Lanier, PT, DPT, OCS
Jennifer Miller, PT, DPT,WCS, CLTDebbie Fleming McDonnell, PT, DPT
Mary Kate McDonnell, PT, DPT, OCS
Patty McGee, PT, DPT, PCS
Tracy Spitznagle, PT, DPT, WCSStacy Tylka, PT, DPT, WCS, CLT
Research Emphasis
Linda Van Dillen, PT, PhD
Barbara Norton, PT, PhD, FAPTASara Gombatto, PT, PhD
Cara Lewis, PT, PhD
Sara Scholtes, DPT, PhDMarcie Harris-Hayes, PT, DPT, MSCI
Mary Hastings, PT, DPT, MSCI, ATC
Program in Physical Therapy
Mosby 2001 Elsevier 2010
Website: https://pt.wustl.edu/Education/ContinuingEducation/Pages/ContinuingEducation.aspx
Program in Physical Therapy
Objectives
• Describe the MSI approach to evaluation and treatment of neuromusculoskeletal pain conditions.
• Describe the normal alignment and movement patterns of the cervical spine, scapula and humerus during selected movements.
• Discuss principles to guide treatment.
• Recognize the importance of individualizing exercise programs for each patient.
Not to be reproduced without permission WPTA 4/21/2017
Sylvia Czuppon PT, DPT, OCS 2
Program in Physical Therapy
The Human Movement System
The Body System for which Physical Therapists are Responsible.
The System of our ExpertiseOur Identity – APTA 2013
Program in Physical Therapy
The Movement System
• Movement is an essential function of life at all levels of living organisms.• From ions moving through
membranes to moving your limbs to moving in your environment
The human movement system is a system of physiological organ systems that interact to
produce movement of the body and its parts. http://pt.wusm.wustl.edu/AboutUs/Pages/Hu
manMovementSystem.aspx
Program in Physical Therapy
Expertise in a Body System is Important
•Highly respected health professions achieved their status by having expertise in an anatomical or a physiological body system
• Pathophysiology of specified anatomical body system• Neurologists, orthopaedists, cardiologists, dentists,
podiatrists
• Physiological systems• Internists (all physiology), endocrinologists
Program in Physical Therapy
Movement System Function Changes With Growth, Activity & Aging:
PT needs to be Life Span Practitioner
• Monitoring and guiding the development of and changes in the Movement System• Alignment, movement patterns, strength, endurance
• Identifying structural variations
If the Oral Cavity needs life-long monitoring the movement system certainly does.
Program in Physical Therapy
Critical Questions
• Is having precise joint movement important?• Are there signs before there are symptoms? (Chol, Blood Sugar, BP)
• Why would the precision of joint movement change – become impaired?• From daily activities
• From sports and fitness
• How should impaired joint motion be corrected?• Stretching
• Strengthening
• Retraining
Program in Physical Therapy
Pain Models:
• Pathokinesiologic Model: Pathology is source of pain
Hislop HJ, Phys Ther, 1975; 19:1069-1080Sahrmann SA, 2002
• Kinesiopathologic Model: Imprecision of movement results in pathology
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Sylvia Czuppon PT, DPT, OCS 3
Program in Physical Therapy
Kinesiopathologic Model of Movement System
Musculoskeletal Nervous
Biomechanics
Repeated movementsSustained alignments
INDUCERSPersonal Characteristics – intrinsicActivity Demands - extrinsic
Tissue Adaptations
Joint AccessoryHypermobility
Relative Stiffness of muscle & connective tissue
Relative FlexibilityIntra-jt + Inter-jt
Micro Macro trauma
Path of Least Resistance
Cardio-Pulmon -endocrine
Motor LearningNeural aff/efferent
Program in Physical Therapy
What is MSI?(Movement System Impairment Syndromes)
• Utilizes the kinesiopathologic model to drive evaluation and treatment of neuromusculoskeletal pain conditions
• Deviations in alignment and the precision of joint motion (movement impairment) create microtrauma that can lead to macrotrauma• In cases of trauma, alterations of normal movement or
alignment will perpetuate the pain
Program in Physical Therapy
Why Does Movement Become Impaired?
• Repeated movements and prolonged postures associated with everyday activities induce adaptive changes in movement system components.
• The adaptive changes vary because of intrinsic (genetics, sex, age) and extrinsic (fitness, work activity) factors.
Program in Physical Therapy
Why Does Movement Become Impaired?
• The body follows the law of physics and follows the path of least resistance for motion which contributes to subtle hypermobility.
• The way everyday activities are performed reinforces this hypermobility and the movement pattern.
• Muscle performance is determined by the pattern of movement. Altered movement patterns impair proper muscle performance.
Program in Physical Therapy
Working Theory
• Musculoskeletal pain is:
1. Related to lifestyle similar to many other health conditions
2. A progressive condition• Starting with acute pain – first indication of tissue damage
• High recurrence rate - leading to chronic problem
3. The result of tissue changes associated with• Aging-related degeneration and
• Activity-induced tissue injury from impaired joint movement
Program in Physical Therapy
The Challenge: Keeping the Acute Problem From Becoming Chronic
• Acute symptoms subside • With time
• With variety of interventions addressing symptoms
• However recurrence is common!• Pathoanatomic structures are traditionally considered the cause.
• Unfortunately, the impaired movement is not considered as cause.• Therefore has not been identified & addressed.
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Sylvia Czuppon PT, DPT, OCS 4
Program in Physical Therapy
The Challenge: Keeping the Acute Problem From Becoming Chronic
• To minimize recurrence, must identify the movement cause & contributing factors
• Develop a treatment program that includes:• Patient specific exercises
• Correction of performance of basic daily activities
• Correction of performance of work, recreation, fitness, & sports activities
Program in Physical Therapy
repetition of Impaired Movement may accelerate the development of osteoarthritis
Program in Physical Therapy
OA Mechanical Mechanisms
• Cartilage degradation can be correlated with abnormal excessive articular contact stress
(Dekeland & Weissman,1978;Brandt 2008; Radin 1978; Jackson 2004; Fontana, 2007)
• This abnormal contact stress may result both • from excessive load acting on a normal joint or
• from normal loading acting on a weakened articulation: ligament laxity, periarticular muscle weakness, or reduced proprioception
• may all lead to articular instability,
• exposing the joint to sudden impulsive loads and finally to high peak pressure
(Brandt 2006; McGonagle 2010; Felson 2000)
Program in Physical Therapy
Unfavorable Biomechanical Conditions Contributing to Development of OA
Mechanism of Relative Overload
Mal-alignment Abnormal load distribution-shifting of center of
pressure
Loss of meniscal tissue > peak pressure
Cartilage lesions > Stress on lesion rim
Joint instability – ligamentous laxity Abnormal load distribution – shifting of center
of pressure
Trauma Cartilage damage
Heijink A, Gomoll AH, Madry H, et. al. Knee Surg Sports Traumatol Arthrosc2012
Program in Physical Therapy
Singer 1993
Degeneration of Cervical Discs
Most affected segments: move with greatest frequencyand range of motion
Program in Physical Therapy
Movement System Impairment (MSI) Syndromes – Guiding Theory
• Little things mean a lot!!!
• Underlying problem: micro-instability:• Accessory motion (roll, spin, glide) becomes excessive in one or more
directions (hypermobility/micro-instability)
• Micro-trauma from shear force and points of high contact pressure
• Becomes macro-trauma
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Sylvia Czuppon PT, DPT, OCS 5
Program in Physical Therapy
Joint Micro-Instability
• Characterized by moving:1. In range that is more than optimal (joint surfaces not optimal
during movement) • Points of high contact stress & shear force
2. More often than is optimal
3. More readily in specific directions
• Results in accessory motion micro-instability
• Can progressively increase
• Can occur with physiological motion that is • Normal
• Excessive
• Limited
Neumann
Program in Physical Therapy
Assessment of Intra-Joint Micro-Instability & Relative Flexibility
• Assess by physiological motions• Passive and active
• Use hands to feel the precision of joint motion
• “Going along for the ride”
• Manually correct the motion during physiological active & passive motion Khoo-Summers L, Manual Therapy 2015
Precise hip flexion Imprecise hip flexion
Program in Physical Therapy
Muscle Stiffness
•Resistance to Passive Stretch
•Highly correlated with muscle size• > size = > stiffness
Program in Physical Therapy
Relative Stiffness
•Daily activities and fitness activities can induce different amounts of muscle hypertrophy across joints
•Hypertrophy of muscle increases the passive stiffness
Program in Physical Therapy
Relative Stiffness
• In a multi-segmented system, • Movement occurs at the segment with the least
resistance/greatest relative flexibility
• Takes the path of least resistance (law of physics)
•Contributes to development of inter-joint relative flexibility • Compensatory movement in specific direction
Program in Physical Therapy
MSI Approach
• Systematic examination used to evaluate, diagnose and treat neuromusculoskeletal pain problems
• Based on anatomy and kinesiology
• Exam is based on symptom alleviation, not just provocation
Not to be reproduced without permission WPTA 4/21/2017
Sylvia Czuppon PT, DPT, OCS 6
Program in Physical Therapy
Cause versus SourceOperational Definitions
Source
• The tissue or pathoanatomical structure that is symptomatic
• e.g. rotator cuff tendin(itis, osis, opathy)
Cause
• The mechanical factor (movement) that results in tissue irritation
• e.g. scapular depression, humeral anterior glide
Program in Physical Therapy
MSI Approach
• Emphasis is on the CAUSE (movement) vs. SOURCE(pathoanatomy) of symptoms
• Identification of the pathoanatomical structure that is the source of symptoms may be useful for prognosis/staging but does not necessarily direct treatment.
• Often > 1 pathoanatomical source
Program in Physical Therapy
Movement Exam
• To date, whether the movement impairment is the cause or result of the pain is unknown.
• But if during the exam, correcting the movement impairment immediately alleviates the symptoms, then treatment may be most effectively directed by a movement diagnosis (Ludewig PM 2009, Kibler WB 2013)
Program in Physical Therapy
Why Give a Diagnosis?
• Direct treatment and describes the syndrome• Shoulder pain vs. Insufficient Scapular Upward Rotation
• Enhance communication• Intra- and extra- professional
• Informs other health professionals of the movement patterns and relationships to pain problems• Facilitate recognition of the profession as movement system experts
• Need label to inform others that we can determine the problem
• Group conditions• Prognosis, etiology, improve treatment, research
Program in Physical Therapy
Movement Exam Diagnosis
• PTs must establish a diagnosis of the condition they are treating to ensure most effective treatment (APTA House of Delegates 1994, 1995)
• Diagnosis named according to the impairment(s) observed• Frequency
• Magnitude
• Production of symptoms
• Response to modification of movement
• Diagnosis directs treatment
Program in Physical Therapy
Movement Examination
• Consists of:• Alignment tests
• Movement tests performed in a variety of positions (standing, supine, prone, quadruped, sitting)
• Analysis of functional activities
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Sylvia Czuppon PT, DPT, OCS 7
Program in Physical Therapy
Movement Examination
• During the examination, the patient’s preferred alignment and movements are analyzed to determine their precision and effect on symptoms.
• The preferred pattern is followed immediately by a secondary test modifying the movement to determine the effect on symptoms.
• Goal: Determine the site that is relatively too flexible (e.g. moves too much)
• Accessory motion that occurs too readily (ex. Superior or anterior glide)
• One joint moving too readily compared to the adjoining joint (ex. GHJ vs scapula)
Program in Physical Therapy
Vicious Cycle
Shoulders forward of hips
In sitting – flexion moment
on lumbar spine
Pelvis tilts posteriorly
Hamstrings become
Short/stiff
Knee extension
Tilts pelvis posteriorly
Flexes lumbar spine
Abdominals become shorter
Flex thoracic and lumbar spine
Sitting erect
Uncomfortable
Back muscles cramp
Feels wrong
Lumbar flexion
Sitting/cycling
/working
Minimal energy expenditure
Passive tension of back extensors
Requires flexion
Not to be reproduced without permission April 21, 2017
Sylvia Czuppon, PT, DPT, OCS 1
Program in Physical Therapy
Link to (most) MSI examination videosand some lecture content
https://wustl.app.box.com/s/mp56h509le7gdmjm4spc4mi4l1frjxhi
Program in Physical Therapy
Movement System Impairment Syndromes of the Cervical Spine
Shirley Sahrmann, PhD, PT, FAPTA and Associates
Presented by: Sylvia Czuppon, PT, DPT, OCS
Associate Professor
Physical Therapy and Orthopaedic Surgery
Twitter: @czuppons
Program in Physical Therapy
Task Force on Neck Pain & Associated Disorders Spine Vol 33, No 45, 2008
• Most people who experience neck pain do not experience a complete reduction of symptoms.
• 50% to 80% will have a reoccurrence in the next 1-5 years
• Prognosis: • Better: Younger
• Poorer: poor health, prior neck pain episodes, poor psychological health, worrying.
Program in Physical Therapy
“Neck pain is multifactorial in its etiology and in its impact on affected persons.
Future research should be directed to assessing the impact of modifiable risk factors through innovative treatment
approaches.
Changes in public policy which address these risk factors may significantly reduce the burden and cost of neck pain in
society.”
Task Force on Neck Pain & Associated Disorders Spine Vol 33, No 45, 2008
Program in Physical Therapy
Alignment: Cervical SpineExamination
Program in Physical Therapy
Optimal Alignment
• Reduces likelihood of postural deformities
• Reduces stress on tissues
• Contributes to optimal movement patterns
• Promotes optimal muscle length and pattern of muscle activation
Kendall FP 1993
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Sylvia Czuppon, PT, DPT, OCS 2
Program in Physical Therapy
Normal Cervical Spine Alignment
•Inward Curve
•Influenced by length of:• Intrinsic muscles of cervical spine•Muscles of shoulder girdle that attach to cervical
spine
•Affected by alignment of thoracic and lumbar spines
Kendall, FP et al, Posture & Pain.
Program in Physical Therapy
Kendall, FP et al, Posture & Pain.
• ↑ thoracic curve = ↑ cervical lordosis = forward head position
• Facets are approximated
• Cervical spine extended and translated
• Increased length of anterior cervical flexor muscles and suprahyoid, infrahyoid muscles
• Decreased length of posterior extensor muscles
Forward Head
Program in Physical Therapy
• Neutral sitting posture• Reduces the demand on the cervical extensor muscles• Improves neck range of motion
Edmondston 2010, Caneiro 2010, Cleland 2009, Lau 2010
Program in Physical Therapy
Black KM et al, Spine 1996
Consideration of Adjacent Regions
• Scapular Alignment
• Thoracic Spine Alignment
• Lumbar Spine Alignment
• Weight of the extremities
• Movement of the extremities
Program in Physical Therapy
• Correcting lumbar, thoracic alignment beforecorrecting cervical spine alignment is critical.
• Ex. Thoracic alignment = kyphosis or sway
• Depressed chest
• Well-developed abdominals
Program in Physical Therapy
Additional Contributing Factors –Shoulder Girdle
• The alignment of the shoulder girdle should be addressed in the treatment of cervical pain problems.
• The musculature of the shoulder girdle affects the alignment and stress on the cervical spine structures.
• Scapular UR & posterior tipping are decreased in flexed head position (Ludewig 1996)
• Position of scapular depression results in increased stress on upper trapezius muscle (Asevedo 2007)
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Sylvia Czuppon, PT, DPT, OCS 3
Program in Physical Therapy
Cervical Motion Restricted by Shoulder Girdle Muscles
• Passive elevation of shoulder girdle increases ROM and decreases pain
• Why? Compressive loading of the cervical spine from a transfer of weight of the upper extremities to the cervical region through cervicoscapular muscle attachments
Ha S et al. Man Ther 2011VanDillen LR et al Clin J Pn 2007Andrade GT et al JOSPT 2008McDonnell MK et al JOSPT 2005
Program in Physical Therapy
Elevated Shoulder Girdle Test
Program in Physical Therapy
Elevated Shoulder Girdle Test
Procedure:
1. Assess AROM and pain/ symptoms.
2. Fully support UEs with muscles relaxed. Reassess AROM and pain/symptoms.
•Can use any cervical active motion, though rotation most common.
•Decreases sx/increases ROM with rotation (Van Dillen 2007)
•Decreases pain with extension (Van Dillen 2007, Ha 2011)
V
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Selected Movement Tests: Cervical SpineExamination
Program in Physical Therapy
Cervical Range of Motion
• Generally, females have greater ROM than males
• Decreases significantly with age
20 – 29 yo
Rotation = 700
Sidebending = 450
Extension = 850
Flexion = 650
70-79 yo
Rotation = 500
Sidebending = 250
Extension = 550
Flexion = 500
Youdas JW et al. PTJ. ’96
Program in Physical Therapy
Vertebral Motions of the Cervical Spine
• Flexion/ Extension: Coupled motion of translation and sagittal rotation
• Sagittal rotation = “Rolling” = rotation about a frontal axis
• Flexion - 630
• Extension - 790
[young adults]
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Sylvia Czuppon, PT, DPT, OCS 4
Program in Physical Therapy
Cervical Flexion
•Lengthening of posterior structures
•Separation of spinous processes
•Full flexion of cervical spine includes upper thoracic flexion
Kendall, FP et al, Posture & Pain.
Program in Physical Therapy
Common Muscle Impairments With Faulty Cervical Flexion
• Intrinsic neck flexors become weak or long -compromise fine control of vertebral motion• Longus capitus, longus colli
•Extrinsic neck flexors become dominant, adding to compressive, rotational, & shear forces exerted on the cervical spine•Anterior and middle scalenes, sternocleidomastoid
• Increase recruitment during anterior translation with flexion (O’Leary 2011)
Mechanical Neck Pain,Porterfield & DeRosa
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Deep/Intrinsic Neck Flexors
• Impairments of the deep neck flexors with patients with dx of Cervicogenic Headaches (CH) & Chronic neck pain patients
Watson DH et al Cephalgia ‘93
Beazell JR Jrnl Man & Manip Th ‘98
Placzek et al Jrnl Man & Manip Th ‘99
Jull et al Cephalgia ’99
Falla D et al, Cl Neurophys’ 06
O’Leary KT et al. Man Ther ’11
• Significant decrease in STRENGTH & ENDURANCE of the deep neck flexors
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Common Muscle Impairments With Faulty Cervical Extension
•Intrinsic neck extensors become weak or long -compromise fine control of vertebral motion•Semispinalis capitis & cervicus, splenius,
suboccipitals
•Extrinsic neck extensors become dominant adding to compressive, rotational, & shear forces exerted on the cervical spine• Levator scapulae, upper trapezius
Mechanical Neck PainPorterfield & DeRosa
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Common Muscle Impairments With Faulty Cervical Rotation
• Intrinsic neck rotators become weak or long -compromise fine control of vertebral motion• Rectus capitis posterior major, oblique capitis inferior,
oblique capitis superior, splenius
•Extrinsic neck rotators become dominant - can produce not only cervical rotation but also lateral flexion, extension and/or forward translation• Sternocleidomastoid, scalenes, upper trapezius, levator
scapulae
Program in Physical Therapy
Movement Impairment Diagnoses of Cervical Spine
• Extension
• Extension-Rotation*
• Flexion
• Flexion-Rotation
• Rotation
* Most common in my practice
**Cervical dx often have an associated scapula and/or humeral movement diagnosis
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Sylvia Czuppon, PT, DPT, OCS 5
Program in Physical Therapy
Cervical Extension –Rotation syndrome
Program in Physical Therapy
Cervical Alignment
•Most common:1. Normal cervical alignment to excessive posterior translation.
Dominant activity of levator scapulae, reduced activity of posterior cervical extensors.
2. Forward head posture (degenerative disc disease) anterior translation limit extension range of motion.
3. Upper cervical extension greater than lower
•May present with rotation or sidebend
Program in Physical Therapy
Alignment
•Thoracic kyphosis increases cervical lordosis
•Scapula depression or abduction• Upper trapezius & levator in a lengthened position
downward pull exerts compressive force on facets narrows intervertebral foramen traction on the brachial plexus
Program in Physical Therapy
Movement Impairments
•Flexion ROM limited or cervical spine does not flex at all segments
•Poor control of motion during active cervical extension and/or rotation
•Shoulder flexion compensatory cervical extension or rotation
•Quadruped rocking compensatory cervical extension
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Cervical Motion Induced by Shoulder Motion
•Shoulder flexion can cause cervical rotation
•Cervical spine relatively more flexible (mobile) than UT or levator
Kendall
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Cervical Extension/Rotation Syndrome
•Key muscle changes:• Short cervical extensors & Long cervical flexors
•Muscle Impairments:•Lengthened intrinsic neck flexors - test weak, decrease
endurance•Dominant extrinsic neck flexors
• Contributes to anterior shear, poor rotation •Dominant levator / upper trapezius
• Contributes to extension and poor rotation
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Sylvia Czuppon, PT, DPT, OCS 6
Program in Physical Therapy
Key Tests
•Pain with neck extension and/or rotation
•Passive elevation of girdle - decrease pain with extension and/or rotation
Van Dillen 2007, Ha 2011
•Limited cervical flexion and/or rotation ROM
•Poor performance of the deep neck flexors
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Treatment
• Start with correct alignment of lumbar, thoracic and scapula before cervical spine alignment
• Improve extensibility of posterior cervical muscles
• Improve intrinsic cervical muscle control and strength
• Improve length of cervical extensors
• Increase support from middle, lower trapezius & serratus anterior to support extremities
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Treatment – Other Education
• Unload spine - support upper extremitiesSchuldt K, Scand J Rehabil Med. 1987
Andrade GT, JOSPT 2008; Ha, Man Ther 2011
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Treatment – Other Education
•Make patient aware of positions and habits that assume positions of extension•Habitual nodding•Use of bifocals•Sleeping with arms overhead•Position of computer
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Activities That Contribute
•Make patient aware of positions and habits that assume positions of rotation•Holding telephone with shoulder•Sitting with head turned watching TV•Sleeping prone with arm overhead and head turned to opposite side
•Sleeping on couch with head resting on arm rest•Falling asleep sitting up•Location of computer screen
Program in Physical Therapy
Movement System ImpairmentDiagnoses – Cervical Spine
•Cervical Extension: Summary•Thoracic kyphosis (increased cervical lordosis)•Scapula depression or abduction (lengths UT and levator – downward pull compresses facets, narrows intervertebral foramen)•Lengthened anterior cervical muscles decreased strength (especially intrinsics)•Shortened, dominant extensors
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Sylvia Czuppon, PT, DPT, OCS 7
Program in Physical Therapy
Movement System ImpairmentDiagnoses – Cervical Spine
•Cervical Rotation: Summary•Often coupled with Extension•Segmental rotation – insufficient control of intrinsic neck flexors and/or extensors•May have pain/excessive cervical movement with unilateral shoulder movements because of attachments of levator scapula and upper trapezius
Not to be reproduced without permission April 21, 2017
Sylvia Czuppon, PT, DPT, OCS 1
Program in Physical Therapy
Link to (most) MSI examination videosand some lecture content
https://wustl.app.box.com/s/mp56h509le7gdmjm4spc4mi4l1frjxhi
Program in Physical Therapy
Movement System Impairment Syndromes of the
Scapula and HumerusShirley Sahrmann, PhD, PT, FAPTA and Associates
Presented by: Sylvia Czuppon, PT, DPT, OCS
Associate Professor
Physical Therapy and Orthopaedic Surgery
Twitter: @czuppons
Program in Physical Therapy
Definitions of Scapular Movements•Adduction (clavicular retraction-SC):
• the scapula translates medially along the rib cage toward the vertebral column.
•Abduction: (clavicular protraction-SC)• translates laterally
•During these motions there is associated scapular internal or external rotation occurring at the AC joint.• Because the scapula follows the ribcage• Thus shape of ribcage is important
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Definitions of Scapular Movements
•Elevation:(clavicular elevation-SC)• a movement in which the scapula translates along the
ribcage in a cranial direction.
•Depression: (clavicular depression-SC)• translates in a caudal direction.
Program in Physical Therapy
Definitions of Scapular Movements• Upward rotation (lateral rotation):
• AC joint
• a movement of the scapula about an axis perpendicular to the plane of scapula
• inferior angle moves laterally
• glenoid fossa rotates to face cranially.
• SC joint
• posterior axial rotation of clavicle also contributes to UR.
• Downward rotation (medial rotation):• inferior angle moves medially
• glenoid fossa rotates to face caudally.
Ludewig PM et al. 2009
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Definitions of Scapular Movements• Anterior tilt/tipping:
• AC joint
• a movement of the scapula about an axis parallel to the scapular spine
• coracoid moves anteriorly and caudally
• inferior angle moves posteriorly and cranially.
• Posterior tilt/tipping:• coracoid moves posteriorly and cranially
• inferior angle moves anteriorly and caudally.
Ludewig PM et al. 2009
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Sylvia Czuppon, PT, DPT, OCS 2
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Definitions of Scapular Movements• Internal rotation:
• AC joint• rotation of the scapula about a vertical axis• lateral border of the scapula moves anteromedially• vertebral border moves posterolaterally such that • the costal surface of the scapula faces more toward the
midline of the body
•External rotation:• lateral border of the scapula moves posterolateral• vertebral border moves anteromedial
Ludewig PM et al. 2009
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Definition of Scapular Movements
•Winging:• AC Joint
• abnormal movement of the scapula about a vertical axis
• vertebral border moves in a posterior direction away from the ribcage (Hall, CM, Brody LT.)
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Alignment: scapula and humerusExamination
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Normal RestingScapulothoracic Alignment
•Slope of shoulders: slight downward slope
•Clavicle:• 6 to 29 elevation Ludewig PM 2009,Todd TW 1912
• 19 retraction Ludewig PM 2009
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Normal Resting Scapulothoracic Alignment
• Scapula: • Root of scapular spine 3” from spinal column
Sobush DB 1996
• 30 - 40 internal rotation (relative to frontal plane)
Lukasiewicz 1999, Neumann 2010, Ludewig PM 2009
• Vertebral border vertical or very slight upward rotation (5o)
Lukasiewicz 1999, Neumann 2010, Ludewig PM 2009
• 10-15 of anterior tilt Ludewig PM 2009
• Root of spine level with T3 Kendall FP 1993, Hoppenfeld S 1976
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Resting Scapulothoracic Alignment
Scapular DepressionNormal
Kendall FP 1993, Hoppenfeld S 1976
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Normal RestingHumeral Alignment
•Humerus•With the scapula aligned correctly:• slight humeral medial rotation – antecubital
crease faces anterior/slightly medial (Ludewig PM 2009)
•arm at side (0oabd)
• shaft of humerus vertical (0o
flexion)
• No > 1/3 humeral head anterior to anterolateral corner of acromion
• Can reliably palpate (Bryde 2004)
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Is Alignment an Initial Indicator of Pattern of Movement?
Alignment may play a greater role in UE pain than other regions of the body
(Swift TR 1984, Borstad JD 2006)
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Selected Movement Tests: ShoulderExamination
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Clinical Assessment: Criteria for Normal Scapular Motion During Arm Elevation
• Scapula upwardly rotates and posteriorly tilts during arm elevation (Ludewig 1996, 2009, Kibler 2009, Lukasiewicz AC 1999, McClure PW 2001)
• Scapula externally rotates during arm elevation especially at the end ranges. (Ludewig 2009, Braman 2009)
• Scapula should elevate slightly (6-10o) (Ludewig PM 2009)
• Vertebral border of scapula should remain in contact with thorax
• Normal GH:ST rhythm is 2.1: for abduction; 2.4:1 for flexion; 2.2:1 for scapular plane abduction (Ludewig PM 2009)
Program in Physical Therapy
Clinical Assessment: Criteria for Normal Humeral Movement During Arm Elevation
• The humerus laterally rotates relative to the scapula as the arm is elevated in all planes• GH LR should be about 60°by the end range of arm elevation
• GH LR increases the volume of the subacromial spaceLudewig PM 2009
• During shoulder flexion, humeral head should stay centered on the glenoid (movement is primarily spinning)
Neumann DA 2002
Program in Physical Therapy
Clinical Assessment: Criteria for Normal Scapular Motion For Shoulder Flexion
By the end range of arm elevation:
• Acromion should be aligned with C6-7
• Root of spine of scapula should be aligned with T3
• The vertebral border of the scapula should reach 55-60
(+ 5). Inman 1944
• Normal scapular abduction is 3” from the vertebral spine to the root of the spine of the scapula.
• Scapula should posteriorly tilt 10 Ludewig PM 2009
• Scapula should externally rotate so it is 10-20 anterior to the frontal plane Ludewig PM 2009
Not to be reproduced without permission April 21, 2017
Sylvia Czuppon, PT, DPT, OCS 4
Program in Physical Therapy
Clinical Assessment: Criteria for Normal Scapular Motion During Arm Lowering
- Pattern of motion should be mirror image of arm elevation (in reverse)
• No prominence of vertebral border
• Scapular posterior tilt should be slightly greater during arm lowering (Ludewig PM 2009)
• There should be decreased scapular relative to GH movement during arm lowering compared to arm raising
(Braman JP 2009)
Program in Physical Therapy
Clinical Assessment: Criteria for Normal Scapula/Humeral Motion - Shoulder Rotation
• Scapula should remain relatively stable• The pull of the rotator cuff muscles should be counteracted by the
scapulothoracic muscles Reinold 2009, Sahrmann 2002
• Humeral rotation should occur about the long axis of the humerus – spinning of humeral head to center on the glenoid (Neumann 2002)
• Translation of the humeral head should not be visible or palpable
Program in Physical Therapy
Movement System ImpairmentDiagnoses: Scapulohumeral
Scapula
• Scapular Internal rotation/ Anterior tilt
• Scapular Depression
• Scapular Downward Rotation
• Scapular Winging
• Scapular Elevation
Humerus
• Humeral Anterior Glide
• Humeral Superior Glide
• Glenohumeral Medial Rotation
• Glenohumeral Hypomobility
• Glenohumeral Multidirectional Accessory Hypermobility
* Revisions to naming of scapular diagnoses may be coming soon, though faulty movement pattern still the same
Program in Physical Therapy
Scapular and Humeral Diagnoses
•Both a scapular & humeral diagnosis can be assigned, if appropriate
•Most patients receive both a scapular and a humeral diagnosis
Program in Physical Therapy
Scapular Diagnoses: Symptoms
Any of the scapular diagnoses can be associated with: • Impingement symptoms:
• GHJ pain, worse with overhead motions or lying on involved side
• Compromise of the brachial plexus (Thoracic outlet syndrome):
• paraesthesia or weakness in the arm; pain in scapula, arm or hand
• Glenohumeral joint instability:
• c/o clunking or sensation of shoulder slipping out of socket
• AC or SC joint pain
• Cervical pain
• Thoracic pain
Program in Physical Therapy
Evidence for Scapular Movement Impairments - Impingement
•Decreased scapular posterior tilting• Lukasiewicz AC et al, JOSPT 1999• Ludewig PM & Cook TM, Phys Therapy 2000• Hebert LJ et al, Arch Phys Med Rehabil,2002• Endo K et al, J Orthop Sci 2001• Lin JJ et al 2006
•Decreased scapular upward rotation• Ludewig PM & Cook TM, Phys Ther 2000• Endo K et al, J Orthop Sci 2001• Lin et al 2006• Lawrence RL 2014
• Increased scapular internal rotation• Warner JP et al, Clin Orthop 1992• Ludewig PM & Cook TM, Phys Ther 2000
Not to be reproduced without permission April 21, 2017
Sylvia Czuppon, PT, DPT, OCS 5
Program in Physical Therapy
Other Findings of Scapular Movement Impairments in Patients with Impingement
• Increased elevation
• Increased upward rotation
•Decreased internal rotation
•The most frequent finding across studies seems to be increased anterior tilt and internal rotation.
From oral presentationCapstone – Emily Schmidt, Jan 2012
Program in Physical Therapy
Evidence - Impingement• Ludewig PM & Cook TM 2000
• increased scapular internal rotation with increased load in symptomatic group (with 5 and 10 lb. load)
• Hebert LJ et al, 2002• found 3 subgroups in subjects with SIS:
• measured only posterior tilt but some had less, some same and some more than controls
• good start at classifying patient into movement impairment categories
Program in Physical Therapy
Evidence for Scapular Movement Impairments - Multidirectional Instability
•Decreased scapular upward rotation and increased scapular internal rotation• Ogston JB, Ludewig PM. Differences in 3-dimensional
shoulder kinematics between persons with multidirectional instability and asymptomatic controls. Am J of Sports Med 2007;35(8):1361-1370
Program in Physical Therapy
Evidence for Humeral Movement Impairments
• Impingement• Increased anterior translation
• Ludewig PM & Cook TM, JOSPT, 2002
• Jobe FW et al, Orthop Rev 1989
• Increased superior translation
• Deutsch A et al, J Shoulder Elbow Surg 1996
•Healthy Individuals• Increased superior translation with muscle fatigue
• Chen SK et al, 1999
Program in Physical Therapy
Definitions•Axiohumeral muscles:
• Muscles from the trunk to the humerus (ie. lats, pectoralis major)
•Axioscapular muscles:• Muscles from the trunk to the scapula (ie. traps, rhomboids,
serratus ant, pec minor)
•Scapulohumeral muscles:• Muscles from the scapula to the humerus
• rotator cuff – supra & infraspinatus, teres minor, subscapularis
• teres major• deltoid
Program in Physical Therapy
Scapular internal rotation with anterior tilt
Not to be reproduced without permission April 21, 2017
Sylvia Czuppon, PT, DPT, OCS 6
Program in Physical Therapy
Scapular Internal RotationWith Anterior Tilt
Movement impairments1. Insufficient scapular external rotation and posterior tilt at
the end range of arm elevation (Ludewig PM 2000 and Lukasiewicz AC 1999, Hebert LJ 2002)
2. Scapular internal rotation and anterior tilt on the return from arm elevation or during early arm elevation due to an issue with patterns of muscle activation
Balance between the serratus anterior and the trapezius is key.
Program in Physical Therapy
Contributing Factors
•Too much scapular internal rotation (often seen with excessive abduction)• Trapezii not performing well, too long, or not as stiff as
muscles that IR and abduct scapula• Serratus anterior not balanced adequately by trapezii• Scapulohumeral muscles pulling harder on scapula than
serratus and trapezii
•Too much scapular anterior tilt• Serratus anterior and lower trapezius not performing well or
not as stiff as muscles that anteriorly tilt scapula• Pectoralis minor too stiff or short
Program in Physical Therapy
Scapular IR – Primary Focus of Intervention
Anterior Tilt and Abduction
• Increase stiffness & activation of posterior axioscapular muscles• Improve timing of activation and hypertrophy
•Stretch• SH muscles while maintaining scapular position• Pectoralis minor
Anterior Tilt - muscle activation
•Dissociating GH from ST motion• “Letting go” with SH muscles• Maintain correct alignment of the scapula during arm
motionsProgram in Physical Therapy
Scapular depression With Insufficient Upward Rotation
Program in Physical Therapy
Scapular DepressionWith Insufficient Upward Rotation
Movement Impairment -Insufficient elevation
• Acromion depresses in the first 90 degrees of shoulder flexion or abduction
• Acromion does not begin to elevate after about 30 degrees of arm elevation
• Acromion below C6 -7 at end range
• Scapula depresses when a load is placed on the arm or during prone tests
Program in Physical Therapy
Scapular DepressionWith Insufficient Upward Rotation
Impairments
• Lengthened or weak• Upper trapezius• Serratus Anterior
• Activation• Excessive – latissimus dorsi and lower
trapezius• Insufficient – upper trapezius
Not to be reproduced without permission April 21, 2017
Sylvia Czuppon, PT, DPT, OCS 7
Program in Physical Therapy
Scapular DepressionWith Insufficient Upward Rotation
Primary Focus of Intervention:
• Patient education regarding the alignment and movement impairments and how to modify them during daily activities• Arm support!
• Correcting stiffness, length, activation, and strength impairments of the upper and middle trapezius
Program in Physical Therapy
Functional Cues
•Reaching:• Gradually lift shoulders (shrug) especially after 90°shoulder
flexion• On return from flexion, don’t let shoulders drop all at once
•Sitting• Support arms at the correct height when sitting to lift
acromions.
•Bra• Decrease load on acromion – sports bra vs. traditional bra
Program in Physical Therapy
Humeral Anterior Glide
Program in Physical Therapy
History
•Pain- ant or post GH joint line > deltoid region
• Impingement- worse with overhead motions or reaching especially backward
• Instability- Complain of clunking or shoulder slipping out of socket; may be associated with trauma; more common in younger population
• Labral Tear- complain of catching or popping deep in the joint, often worse with rotation in elevated arm position
Program in Physical Therapy
Humeral Anterior Glide
•May have general hypermobility
•Activities/habits• Racquet or throwing sports, volleyball, swimming
• Stand with hands clasped behind back
• Standing with arms crossed across chest
• Reaching out to the side or behind
Program in Physical Therapy
Humeral Anterior Glide
•Movement Impairment• Excessive or abnormal anterior motion of the humeral head
during shoulder motionsLawrence RL 2014, Caldwell 2007, Ludewig PM 2002, Harryman DT 1990
• May decrease the volume of subacromial space
•Relative Flexibility• The anterior joint capsule is more flexible than the posterior
joint capsule and/or the lateral rotators
Not to be reproduced without permission April 21, 2017
Sylvia Czuppon, PT, DPT, OCS 8
Program in Physical Therapy
Humeral Anterior Glide
Alignment Impairments• forward shoulders
• greater than 1/3rd of the humeral head anterior of the acromion
• proximal humeral head anterior to the distal end of the humerus
• indentation below acromion posteriorly
Program in Physical Therapy
Resting Alignment of Shoulder Extension
Program in Physical Therapy
Humeral Anterior Glide
• Impairments in Muscle Activation and Lengths
• Dominance of posterior deltoid over infraspinatus & teresminor during lateral rotation resulting in:
• GH extension or horizontal abduction • Associated with scapular internal rotation/anterior tilt
• Dominance or shortness of pectoralis major over rotator cuff muscles
Jaggi A 2012
Program in Physical Therapy
Humeral Anterior Glide
• Impairments in Muscle Strength, Stiffness, and Length
• weak or lengthened subscapularis > teres major
Turkel SJ 1981, Pennock 2011
• short or stiff posterior capsule & scapulohumeral lateral rotators (infraspinatus, teres minor, posterior deltoid)
Program in Physical Therapy
Humeral Anterior Glide
Short or stiff posterior capsule of GH joint• Tests to assess the length/stiffness of the posterior structures
of GH joint are supine MR, horizontal adduction, and shoulder flexion at 90 degrees with MR.
Ludewig PM 2002, Tyler TF 1999, Warner JJ 1990,
Pappas AM 1985, Borstad JD 2011
Program in Physical Therapy
Key TestsStanding
• Shoulder abduction - GHJ in horizontal abduction
• Shoulder lateral rotation
Supine
• GHJ medial rotation (MR)– ROM limited and anterior glide present
• GHJ lateral rotation (LR)– ROM may be excessive, anterior glide present
• Horizontal adduction – ROM limited
Prone
• Prone middle trapezius test – muscle recruitment pattern vs. muscle strength test
Not to be reproduced without permission April 21, 2017
Sylvia Czuppon, PT, DPT, OCS 9
Program in Physical Therapy
Treatment
• Correct scapular motion during glenohumeral motion: elevation, posterior tilt, upward rotation or external rotation/adduction
McMahon PJ 1996
• Training for precise humeral rotation pattern before strengthening
Falla A 2003
• Lengthen lateral rotators & posterior capsuleHarryman DT 1990; Ludewig PM 2002 2003;
Bang MD 2000; Budoff JE 2005; McClure PW 2004, 2007
Tyler TF 2000; Wilk KE 2002
Program in Physical Therapy
Stretch posterior capsule
•Horizontal adduction of humerus• “Improvement in IR from cross-body stretch was
greater than for the sleeper stretch” McClure 2007
•Sleeper stretch- too much compression on joint
•Assess this also with the shoulder in LR
Program in Physical Therapy
Support in Literature for Stretching Posterior Structures (Patients with Impingement)
•Harryman DT et al, 1990 •McClure P, et al. JOSPT 2007;37(3).•Bang MD, Deyle GD, 2000•Budoff JE, 2005• Ludewig PM, Borstad JD, 2003•Matsen FA, Arntz CT, 1990•McClure PW et al, 2004•Tyler TF et al, 2000•Wilk KE et al, 2002
Program in Physical Therapy
Treatment
• Decrease activation of posterior deltoid – alignment
• Decrease recruitment of pectoralis major and latissimus Jaggi A 2012
• Shorten/stiffen subscapularisArroyo 1997, Glousman R 1988
Habermeyer P 2004, Jobe CM 1996Pennock AT 2011, Symeonides PP 1972, Turkel SJ 1981
• Perform isometrics in as much IR as possible to isolate subscapularis vs. pec major, lats, teres major (Suenaga N 2003, Pennock AT 2011)
• Perform isotonics in >45o abduction (Ackland DC 2011)
Program in Physical Therapy
Functional Cues
•During humeral horizontal abduction or reaching to the side - lead with scapular adduction/external rotation and possibly increase thoracic/trunk rotation
•Educate: relationship of the humeral position - distal vs proximal end•Avoid humeral positions that elongate ant/inf capsule
Program in Physical Therapy
General MSI Treatment Guidelines
Not to be reproduced without permission April 21, 2017
Sylvia Czuppon, PT, DPT, OCS 10
Program in Physical Therapy
“Muscle performance is determined by the pattern of movement. Correction of faulty patterns is best achieved by training the correct
pattern and not by isolated ‘strengthening’ of a muscle.
…
The critical issue is how an activity is performed not just performing the activity.”
(MSI Syndromes of the Extremities, 2011)
Program in Physical Therapy
General Treatment Goals
• Redistribute movement to appropriate joints
• Correct the movement pattern that is causing the tissue to become painful rather than direct treatment to the affected tissue.
• Training proper movement patterns will induce appropriate muscular (strength, length) and biomechanical adaptations that will reinforce the development of optimal neuromuscular action
Program in Physical Therapy
Treatment
• Movement Diagnosis directs treatment
• Correct alignment and movement during functional activities
• Prescribe corrective exercise program: • Emphasizes precise motion
• Individualized to the patient
• Practice performing movements using the corrected or modified strategy
Program in Physical Therapy
Treatment
• Because treatment is addressing cause of symptoms, pain reduces as tissue stresses are reduced• Recurrence less likely if cause of pain is addressed
• Source of pain indirectly addressed
Mueller and Maluf2002
= Pain
Program in Physical Therapy
Treatment of Relative Flexibility
Incorporate the following principles into functional activities and exercises as often as possible
• Prevent repeated stretching of flexible site
• Improve performance of stabilizing muscles• Active contraction at desired length
• Stiffen and shorten long muscles
• Stretch short/stiff muscles
Program in Physical Therapy
Take Home Messages
• The body follows the path of least resistance for motion which contributes to subtle hypermobility.
• The way everyday activities are performed reinforces this hypermobility and the movement pattern.
• Muscle performance is determined by the pattern of movement. Altered movement patterns impair proper muscle performance.
Not to be reproduced without permission April 21, 2017
Sylvia Czuppon, PT, DPT, OCS 11
Program in Physical Therapy
Take Home Messages
• During exam, when a movement does not appear ideal or causes symptoms, try to modify movement.• Doing this repeatedly during the exam helps confirm
diagnosis
• Think “big picture” – how do the findings of the exam relate to one another?
• Diagnosing is based on pattern recognition
Program in Physical Therapy
Take Home Messages
•Treatment:
1) Correct the pattern of motion to restore more precise joint motion
2) Correct functional activity performance
3) Individualized to each patient
Shoulder References
1. Ackland DC, Pandy MG. Moment arms of the shoulder muscles during axial
rotation. J Orthop Res. 2011;29:658-667.
2. American Academy of Orthopaedic Surgeons: Atlas of Orthotics: Biomechanical Principles and Application. St. Louis, MO, C.V. Mosby Company, 1975
3. Arroyo JS, Hershon SJ, Bigliani LU. Special considerations in the athletic
throwing shoulder. Orthop Clin North Am. 1997;28:69-78.
4. Babyar SR. Excessive scapular motion in individuals recovering from painful and stiff shoulders; causes and treatment strategies. Phys Ther. 1996;76:226-238; discussion 239-247.
5. Bagg SD, Forrest WJ: A Biomechanical Analysis of Scapular Rotation during Arm
Abduction in the Scapular Plane. American Journal of Physical Medicine & Rehabilitation, 238-245, Williams & Wilkins, 1988
6. Bang MD, Deyle GD. Comparison of supervised exercise with and without
manual physical therapy for patients with shoulder impingement syndrome. J Orthop sports Phys Ther. 2000;30:126-137.
7. Borich MR, Bright JM, Lorello DJ, Cieminski CJ, Buisman T, Ludewig PM.
Scapular angle positioning at end range internal rotation in cases of glenohumeral internal rotation deficit. J Orthop Sports Phys Ther 2006;36(12):926-934.
8. Borstad JD, Ludewig PM: Comparison of scapular kinematics between elevation
and lowering of the arm in the scapular plane. Clinical Biomechanics 17:650-659, 2002
9. Borstad JD, Ludewig PM. The effect of long versus short pectoralis minor resting
length on scapular kinematics in healthy individuals. J Orthop Sports Phys Ther. 2005;35:227-238.
10. Borstad JD, Ludewig PM. Comparison of three stretches for the pectoralis minor
muscle. J Shoulder Elbow Surg 2006;15:324-330
11. Borstad JD. Resting position variables at the shoulder: evidence to support a posture-impairment association. Phys Ther 2006; 86(4):549-557.
12. Borstad JD, Mathiowetz KM, Minday LE, Prabhu B, Christopherson DE, Ludewig PM. Clinical measurement of posterior shoulder flexibility. Manual Therapy 2007; 12: 386-389.
13. Borstad JD, Dashottar A. Quantifying Strain on Posterior Shoulder Tissues
During 5 Simulated Clinical Tests: A Cadaver Study. J Orthop Sports Phys Ther. 2011; 41(2):90-99
14. Braman JP, Engel SC, LaPrade RF, Ludewig PM. In vivo assessment of scapulohumeral rhythm during unconstrained overhead reaching in asymptomatic subjects. J Shoulder Elbow Surg 2009;18:960-967.
15. Brindle TJ, Nitz AJ, Uhl TL, Kifer E, Shapiro R. Measures of accuracy for active
shoulder movements at 3 different speeds with kinesthetic and visual feedback. J Orthop Sports Phys Ther. 2004;34:468-478.
16. Bryde D, Freure J, Jones L, Werstine M, Briffa NK. Reliability of palpation of
humeral head position in asymptomatic shoulders. Manual Therapy 2005;10:191-197.
17. Budoff JE. The etiology of rotator cuff disease and treatment of partial-thickness
pathology. JASSH. 2005;5:139-152.
18. Bullock MP, Foster NE, Wright CC. Shoulder impingement: the effect of sitting posture on shoulder pain and range of motion. Man Ther. 2005:10(1);28-37.
19. Cailliet R: Shoulder Pain Ed 2, Philadelphia, PA: F.A. Davis Company; 1981.
20. Caldwell CA, Sahrmann SA, Van Dillen LR. Use of a movement system
impairment diagnosis for physical therapy in the management of a patient with shoulder pain. J Orthop Sports Phys Ther 2007;37(9):551-563.
21. Chen SK, Simonian PT, Wickiewicz TL, Otis JC, Warren RF. Radiographic
evaluation of glenohumeral kinematics: a muscle fatigue model. J Shoulder Elbow Surg.1999;8:49-52.
22. Cools AM, Witvrouw EE, Declercq GA, Danneels LA, Cambier DC. Scapular
muscle recruitment patterns: trapezius muscle latency with and without impingement symptoms. Am J Sports Med. 2003;31:542-549.
23. Cools AM, Dewitte V, Lanszweert F, Notebaert D, Roets A, Soetens B, Cagnie B, Witvrouw EE. Rehabilitation of scapular muscle balance: which exercises to prescribe? Am J Sports Med 2007;35:1744-1751.
24. Deutsch A, Altchek DW, Schwartz E, et al: Radiologic measurement of superior displacement of the humeral head in the impingement syndrome. Journal of Shoulder & Elbow Surgery, 1996; 5(3):186-193.
25. Endo K, Ikata T, Katoh S, et. al: Radiographic assessment of scapular rotational tilt in chronic shoulder impingement syndrome. J Orthop Sci 2001;6:3-10
26. Fey AJ, Dorn CS, Busch BP, Laux LA, Hassett DR, Ludewig PM. Potential torque capabilities of the trapezius. JOSPT. 2007:37(1); A44-45. - Abstract
27. Glousman R, Jobe F, Tibone J, Moynes D, Antonelli D, Perry J. Dynamic electromyographic analysis of the throwing shoulder with glenohumeral instability. J Bone Joint Surg Am. 1988;70:220-226.
28. Habermeyer P, Magosch P, Pritsch M, Scheibel MT, Lichtenberg S. Anterosuperior impingement of the shoulder as a result of pulley lesions: a prospective arthroscopic study. J Shoulder Elbow Surg. 2004;13:5-12.
29. Hall CM, Brody LT. Therapeutic Exercise: Moving Toward Function. Philadelphia,
PA: Lippincott Williams & Wilkins; 1999.
30. Hardwick DH, Beebe JA, McDonnell MK, Lang CE. A comparison of serratus anterior muscle activation during a wall slide exercise and other traditional exercises. J Orthop Sports Phys Ther. 2006; 36(12):903-910.
31. Harris-Hayes M, Van Dillen LR, Sahrmann SA. Classification, treatment and outcomes of a patient with lumbar extension syndrome. Physiother Theory Pract. 2005;21:181-196.
32. Harryman DT, Sidles JA, Clark JM, et al: Translation of the Humeral Head on the Glenoid with Passive Glenohumeral Motion. The Journal of Bone and Joint Surgery, 72-A(9): 1334-1343, October, 1990
33. Hassett DR, Phadke V, Braman JP, LaPrade RF, Ludewig PM. Thoracic
contributions to normal scapular kinematics. JOSPT. 2007:37(1);A63-64. Abstract
34. Hebert LJ, Moffet H, McFayden BJ, Dionne CE. Scapular behavior in shoulder
impingement syndrome. Arch Phys Med Rehabil. 2002:83(1);60-69.
35. Hoppenfeld S. Physical Examination of the Spine and Extremities. Norwalk, CT: Appleton-Centruy-Crofts;1976.
36. Host HH. Scapular taping in the treatment of anterior shoulder impingement. Phys Ther. 1995;75(9):803-812.
37. Ide J, Kataoka Y, Yamaga M, Kitamura T, Takagi K. Compression and stretching of the brachial plexus in thoracic outlet syndrome:correlation between neuroradiographic findings and symptoms and signs produced by provocation
manoeuvres. Journal of Hand Surgery (British and European Volume 2003;28B(3):218-223.
38. Inman VT, Saunders JB, Abbott LC. Observations of the function of the shoulder joint. J Bone Joint Surg Am. 1944:3-12.
39. Jaggi A, Noorani A, Malone A, Cowen J, et al. Muscle activation patterns in patients with recurrent shoulder instability. Int J Shoulder Surg. 2012; 6(4): 101–107
40. Jobe CM. Superior glenoid impingement. Current concepts. Clin Orthop Relat
Res. 1996;98-107.
41. Jobe Fw, Kvitne RS, Giangarra CE. Shoulder pain in the overhand or throwing athlete. The relationship of anterior instability and rotator cuff impingement. Orthop Rev. 1989;18:963-975.
42. Kalra N, Seitz AL, Boardman III ND, Michener LA. Effect of posture on acromiohumeral distance with arm elevation in subjects with and without rotator cuff disease using ultrasonography. J Orthop Sports Phys Ther 2010;40(10):633-640.
43. Kendall HO, Kendall FP, Boynton DA. Posture and Pain. Baltimore, MD, Williams
& Wilkins, 1952.
44. Kendall FP, McCreary EK. Muscles, Testing and Function. ed 3. Baltimore, MD, Williams & Wilkins, 1952.
45. Kendall FP, McCreary EK, Provance PG. Muscles: Testing and Function.
Baltimore, MD: Williams & Wilkins; 1993.
46. Kibler WB: The Role of the Scapula in Athletic Shoulder Function. American Journal of Sports Medicine, 26(2): 325-337, 1998.
47. Kibler WB, Uhl TL, et al: Qualitative clinical evaluation of scapular dysfunction: a
reliability study. J Shoulder Elbow Surg, 11(6): 550-556, November/December, 2002.
48. Kibler WB, Ludewig PM, McClure P, Uhl TL, Sciascia A. Scapular Summit 2009: introduction. J Orthop Sport Phys Ther 2009;39(11):A1-13.
49. Kibler WB, McMullen J. Scapular dyskinesias and its relation to shoulder pain. J Am Acad Orthop Surg. 2003;11:142-151.
50. Kibler WB, Sciascia MS, Wilkes T. Scapular dyskinesis and its relation to shoulder injury. J Am Acad Orthop Surg. 2012; 20: 364-372
51. Kibler WB, Ludewig PM, McClure PW, et al. Br J Sports Med 2013;47:877–885.
52. LaPrade RF, Wickum DJ, Griffith CJ, Ludewig PM. Kinematic evaluation of the modified weaver-dunn acromioclavicular joint reconstruction. Am J Sports Med. 2008;36(11):2216-2221.
53. Lawrence RL Braman JP, LaPrade RF, Ludewig PM. Comparison of 3-Dimensional Shoulder Complex Kinematics in Individuals With and Without Shoulder Pain, Part 1: Sternoclavicular, Acromioclavicular, and Scapulothoracic Joints. J Orthop Sport Phys Ther. 2014; 44(9):636-645
54. Lewis JS, Valentine RE. The pectoralis minor length test: a study of the intra-
rater reliability and diagnostic accuracy in subjects with and without shoulder symptoms. BMC Musculoskeletal Disorders 2007;8:64. Available from http://www.biomedcentral.com.
55. Lewis JS, Wright C, Green A. Subacromial impingement syndrome: the effect of
changing posture on shoulder range of movement. J Orthop Sport Phys Ther. 2005;35:72-87.
56. Lin JJ, Hanten WP, Olson SL et al. Shoulder dysfunction assessment: self-report
and impaired scapular movements. Phys Ther 2006;86(8):1065-1074.
57. Ludewig PM, Phadke V, Braman JP, Hassett DR, Cieminski CJ, LaPrade RF. J Bone Joint Surg Am. 2009;91:378-389.
58. Ludewig PM, Behrens SA, et al: Three-Dimensional Clavicular Motion During
Arm Elevation: Reliability and Descriptive Data. JOSPT, 34(3):140-149, March, 2004
59. Ludewig PM, Borstad JD. Effects of a home exercise programme on shoulder
pain and functional status in construction workers. Occup Environ Med. 2003;60:841-849.
60. Ludewig PM, Cook TM: Translations of the Humerus in Persons With Shoulder
Impingement Symptoms. JOSPT, 32(6): 248-259, June, 2002
61. Ludewig PM, Cook TM: Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement. Phys Ther. 2000;80:276-291.
62. Ludewig PM, Cook TM, Nawoczenski DA: Three-Dimensional Scapular
Orientation and Muscle Activity at Selected Positions of Humeral Elevation. JOSPT, 24(2):57-65, August, 1996
63. Ludewig PM Phadke V, Braman JP, Hassett DR, Cieminski CJ, LaPrade RF. Motion of the shoulder complex during multiplanar humeral elevation. J Bone Joint Surg Am. 2009;91:378-389
64. Ludewig PM, Reynolds JF. The association of scapular kinematics and glenohumeral joint pathologies. JOSPT 2009;39(2):90-104
65. Ludewig PM, Phadke V, Hassett DR, Cieminski CJ, Braman FP, LaPrade RF.
Direct measurement of the strernoclavicular and acromioclavicular joints during elevation of the arm. JOSPT. 2007:37(1);A22-23. Abstract
66. Lukasiewicz AC, McClure P, Michener L, et al. Comparison of 3-DImensional
Scapular Position and Orientation Between Subjects With and Without Shoulder Impingement, Journal of Orthopaedic & Sports Physical Therapy, 1999; 29(10): 574-586, October, 1999
67. Lunden JB, Braman JP, LaPrade RF, Ludewig PM. Shoulder kinematics during the wall push-up plus exercise. J Shoulder Elbow Surg 2010;19:216-223
68. Maluf KS, Sahrmann SA, Van Dillen LR. Use of a classification system to guide
nonsurgical management of a patient with chronic low back pain. Phys Ther. 2000;80:1097-1111.
69. Matsen FA, Arntz CT. Subacromial impingement. In Rockwood CA, Matsen FA (eds): The Shoulder. Philadelphia, WB Saunders, 1990, p 628.
70. Matsumura N, Ikegami H, Nakamichi N, et al. Effect of shortening deformity of the clavicle on scapular kinematics: A cadaveric study. Am J Sports Med. 2010:38(5):1000-1006.
71. McClure PW, Bialker J, Neff N, Williams G, Karduna A. Shoulder function and 3-dimensional kinematics in people with shoulder impingement syndrome before and after a 6-week exercise program. Phys Ther. 2004;84:832-848.
72. McClure PW, Michener LA, Sennett BJ, Karduna AR. Direct 3-dimensional
measurement of scapular kinematics during dynamic movements in vivo. J Shoulder Elbow Surg. 2001;10:269-277.
73. McClure PW, Balaicuis J, Heiland D, Broersma ME, Thorndike CK, Wood A. A
randomized controlled comparison of stretching procedures for posterior shoulder tightness. JOSPT. 2007;37(3):108-114.
74. McClure P, Tate AR, Kareha S, Irwin D, Zlupko E. A clinical method for identifying scapular dyskinesis, Part I: reliability. J Athl Trng 2009;44(2):160-164.
75. McLean L. The effect of postural correction on muscle activation amplitudes recorded from the cervicobrachial region. J Electromyogr Kinesiol. 2005;15:527-535.
76. McMahon PJ, Jobe FW, Pink MM, et al: Comparative electromyographic analysis of shoulder muscles during planar motions: Anterior glenohumeral instability versus normal. J. Shoulder Elbow Surg. 5(2), Part 1: 118-123, March/April, 1996
77. Michener LA, McClure PW, Karduna AR. Anatomical and biomechanical mechanisms of subacromial impingement syndrome. Clin Biomech (Bristol, Avon). 2003;18:369-379.
78. Morrey BF, An K. Biomechanics of the shoulder. In: Rockwood CAJ, Matsen FAI,
eds. The Shoulder. Philadelphia, PA: W.B. Saunders; 1990.
79. Moseley JB, Jr., Jobe FW, Pink M, Perry J, Tibone J. EMG analysis of the scapular muscles during a shoulder rehabilitation program. Am J Sports Med. 1992;20:128-134.
80. Muraki T, Aoki M, Izumi T, Fujii M, Hidaka E, Miyamoto S. Lengthening of the pectoralis minor muscle during passive shoulder motions and stretching techniques: a cadaveric biomechanical study. Physical Therapy 2009; 89(4):333-341.
81. Nakatsuchi Y, Saitoh S, Hosaka M, Matsuda S. Conservative treatment of thoracic outlet syndrome using an orthosis. J Hand Surg [Br]. 1995;20(1):34-39
82. Neer II, C.S: Impingement Lesions. Clinical Orthopedics and Related Research, No. 173, March, 1983
83. Netter FH: The CIBA Collection of Medical Illustrations, Musculoskeletal System,
Part 1: Anatomy, Physiology and Metabolic Disorders. Volume 8, Summit, NJ, CIBA-GEIGY Corporation, 1987
84. Neumann DA. Kinesiology of the Musculoskeletal System: Foundations for
Physical Rehabilitation. St Louis, MO: Mosby; 2002.
85. Ogston JB, Ludewig PM. Differences in 3-dimensional shoulder kinematics between persons with multidirectional instability and asymptomatic controls. Am J of Sports Med 2007;35(8):1361-1370
86. Pappas AM, Zawacki RM, McCarthy CF. Rehabilitation of the pitching shoulder.
Am J Sports Med. 1985;13:223-235.
87. Pennock AT, Pennington WW, Torry MR et al. The influence of arm and shoulder position on the bear-hug, belly-press, and lift-off tests: an electromyographic study. Am J Sports Med. 2011; 39:2338-2346.
88. Petersson CJ, Relund-Johnell I. The subacromial space in normal shoulder
radiographs Acta Orthop Scand 1985;55:57-58.
89. Phadke V, Hassett DR, Cieminski CJ, Braman JP, LaPrade RF, Ludewig PM. Direct measurement of dynamic 3-dimensional motion at the glenohumeral joint. JOSPT. 2007;37(1):A54-55. Abstract
90. Ogston JB, Ludewig PM. Differences in 3-dimensional shoulder kinematics
between persons with multidirectional instability and asymptomatic controls. JOSPT. 2007;37(1):A43-44. Abstract
91. Ozaki J: Glenohumeral Movements of the Involuntary Inferior and Multidirectional Instability. Department of Orthopaedic Surgery, Nara Medical University, Kashihara, Nara, Japan, 107-111, December, 1987
92. Ozaki J: Glenohumeral Movements of the involuntary inferior and multidirectional
instability. Clinical Orthopedics and Related Research, 1989; 238:107-111.
93. Rabin A, Irrgang JJ, Fitzgerald GK, Eubanks A. The intertester reliability of the scapular assistance test. JOSPT. 2006:36(9);653-660.
94. Sahrmann SA. Diagnosis and Treatment of Movement Impairment Syndromes.
St Louis, MO: Mosby; 2002.
95. Scovazzo ML, Browne A, Pink M, Jobe FW, Kerrigan J. The painful shoulder during freestyle swimming. An electromyographic cinematographic analysis of twelve muscle. Am J Sports Med. 1991;19:577-582.
96. Silva RT, Hartmann LG, de Souza Laurino CF, Rocha Bilo JP. Clinical and ultrasonographic correlation between scapular dyskinesia and subacromial space measurement among junior elite tennis players. Br J Sports Med 2010;44:407-410.
97. Sobush DC, Simoneau GG, Dietz KE et al. The Lennie test for measuring scapular position in healthy young adult females: a reliability and validity study. JOSPT 23(1):39-50, January 1996
98. Solem-Bertoft E, Thuomas KA, Westerberg CE. The influence of scapular
retraction and protraction on the width of the subacromial space. An MRI study. Clin Orthop Relat Res. 1993:99-103.
99. Swanik KA, Lephart SM, Swanik CB, Lephart SP, Stone DA, Fu FH. The effects
of shoulder plyometric training on proprioception and selected muscle performance characteristics. J Shoulder Elbow Surg. 2002;11:579-586.
100. Swift TR, Nichols FT: The droopy shoulder syndrome. Neurology, 34: 212-215, February, 1984
101. Symeonides PP. The significance of the subscapularis muscle in the
pathogenesis of recurrent anterior dislocation of the shoulder. J Bone Joint Surg Br. 1972;54:476-483.
102. Tate AT, McClure PW, Kareha S, Irwin D. Effect of the scapula reposition
test on impingement symptoms and elevation strength in overhead athletes. JOSPT. 2008;38(1):4-11.
103. Tate AR, McClure P, Kareha S, Irwain D, Barbe MF. A clinical method for identifying scapular dyskinesis, Part 2: validity. J of Athl Trng 2009;44(2):165-173
104. Telford ED, Motterhead S. Pressure at the cervico-brachial junction: an operative and anatomical study. J Bone Joint Surg [Br] 1948;30(2): 249-265
105. Todd TW: The Descent of the Shoulder after Birth. Anat. Anz. Bd. Aufsatze, 41(14): 385-397, 15. June, 1912
106. Travell JG, Simons DG: Myofascial Pain and Dysfunction: The Trigger
Point Manual. Baltimore, MD, WIlliams & Wilkins, 1983
107. Turkel SJ, Panio MW, et al: Stabilizing Mechanisms Preventing Anterior Dislocation of the Glenohumeral Joint. The Journal of Bone and Joint Surgery, 63-A(8): 1208-1217, October, 1981
108. Tyler TF, Nicholas SJ, Roy T, Gleim GW. Quantification of posterior capsule
tightness and motion loss in patients with shoulder impingement. Am J Sports Med. 2000;28:668-673.
109. Tyler TF, Roy T, Nicholas SJ, Gleim GW. Reliability and validity of a new
method of measuring posterior shoulder tightness. J Orthop Sports Phys Ther. 1999;29:262-269.
110. Uhl TL, Carver TJ, Mattacola CG, Mair SD, Nitz AJ. Shoulder musculature
activation during upper extremity weight-bearing exercise. J Orthop Sports Phys Ther. 2003;33:109-117.
111. Van Dillen LR, Sahrmann SA, Wagner JM. Classification, intervention, and
outcomes for a person with lumbar rotation with flexion syndrome. Phys Ther. 2005;85:336-351.
112. Warner JP, Mitcheli LJ, Arslanian LE, et al: Patterns of flexibility, laxity, and
strength in normal shoulders and shoulders with instability and impingement. Am J Sports Med. 1990;18:366-375.
113. Warner JP, Mitcheli LJ, Arslanian LE, et al: Scapulothoracic motion in normal
shoulders and shoulders with glenohumeral instability and impingement syndrome. A study using Moire toppgraphic analysis. Clin Orthop Relat Res. 1992:191-199.
114. Wilk KE, Meister K, Andrews JR. Current concepts in the rehabilitation of the
overhead throwing athlete. Am J Sports Med. 2002;30:136-151.
115. Williams C, Jones D, Webb L, Kulaski R, Halle JS, Robinson KT. The effect of fatigue on the muscle latencies and mean amplitudes of the 3 portions of the trapezius, serratus anterior, and deltoid muscles in healthy shoulders. JOSPT. 2007;37(1):A70. Abstract
116. Wise MB, Uhl TL, Mattacola CG, Nitz AJ, Kibler WB. The effect of limb support
on muscle activation during shoulder exercises. J Shoulder Elbow Surg. 2004;13:614-620.
MSI UQ 2016
WASHINGTON UNIVERSITY SCHOOL OF MEDICINE
PROGRAM IN PHYSICAL THERAPY
UPPER QUARTER EXAMINATION
For each exam item, observe the patient’s preferred alignment or movement strategy and obtain symptom
response from the patient. If an impairment of alignment or movement is observed, repeat the exam item
with the appropriate correction/modification and again obtain the patient’s symptom response.
A. STANDING
1. Alignment: head, neck, thorax, shoulders, scapula, clavicle, humerus (UQ)
2. Thoracic flexion (UQ)
3. Thoracic rotation (Th)
4. Thoracic side bending (Th)
5. Bilateral shoulder flexion and return from flexion (UQ)
6. Shoulder abduction (UQ)
7. Single shoulder flexion (CS, Th)
8. Shoulder external rotation with arm at side and elbow flexed (Sh)
9. Ventilation (Th)
10. Cervical Range of Motion (CS) (can be performed in standing or sitting)
w/passive elevated shoulder girdle test
B. SUPINE
1. Alignment: head, neck, thorax, shoulders, scapula, humerus (UQ)
2. Pectoralis minor length test (UQ)
3. Latissimus dorsi length test (UQ)
4. Scapulohumeral length test (UQ)
5. Pectoralis major length test (UQ)
6. Passive shoulder abduction (UQ)
7. Shoulder internal and external rotation arm abducted (muscle performance and ROM) (Sh)
8. Shoulder external rotation with arm adducted (Sh)
9. Posterior deltoid/capsule length test (Sh)
10. Biceps brachii length test (Sh)
11. Cervical flexion (ROM and Intrinsic cervical flexor muscle performance) (CS)
12. Cervical rotation (CS)
13. Lower Abdominal muscle performance (UQ)
Subcostal margin (Th)
C. PRONE
1. Shoulder external and internal rotation (muscle performance and ROM) (Sh)
2. Lower trapezius muscle performance (UQ)
3. Middle trapezius muscle performance (UQ)
4. Rhomboids muscle performance (UQ)
5. Cervical extension
D. QUADRUPED
1. Alignment: head, neck, thorax, shoulders, scapula, humerus (UQ)
2. Cervical flexion,extension, rotation (CS)
3. Rocking backward (UQ)
4. Shoulder flexion (CS, Th)
E. SITTING TEST
1. Serratus anterior muscle performance (UQ)
2. Upper trapezius muscle performance (Sh)
3. Cervical rotation (CS)
w/ passive elevated shoulder girdle test
MSI UQ 2016
F. FUNCTIONAL ACTIVITIES (UQ)
1. Sitting alignment
Arm support
2. Sleeping position
3. Work station
Phone use
Filing
Computer/monitor location
4. Sporting/Fitness activities
5. Reading position
Bifocals
Driving
G. ADDITIONAL TESTS
1. Shoulder flexion and abduction with back against the wall (UQ)
2. Shoulder flexion facing the wall (UQ)
Abbreviations
CS = Test items performed to assess movement impairments of the cervical spine.
Sh = Test items performed to assess movement impairments of the shoulder.
Th = Test items performed to assess movement impairments of the thoracic spine.
UQ = Test items performed to assess movement impairments of the upper quarter.
03/19/04