1. + Scapular Dyskinesia and its Relationship to Rotator Cuff Impingement Syndrome Nadir Mawji MSc PT Student Year 2 May 16, 2013

2. + 3. + 4. + 5. + Scapulohumeral Rhythm 6. + 7. + 8. + 9. + 10. + Why Supraspinatus? 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. + Impingement Syndrome Exercises (Kuhn, 2009) 13. + Impingement Syndrome Exercises (Kuhn, 2009) 14. + 15. + 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. + 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. + 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. + 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. + Identification of Scapular Dyskinesia Observation: SICK posture (Burkhart, 2003) Scapular malposition Inferior medial border prominence Coracoid pain and malposition Dyskinesis of scapular movement 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. + Scapular Assistance Test Used in evaluating scapular contributions to impingement and RC strength 24. + Test Time! 25. + Inferior Glide Exercise (LFT) 26. + Low Row (LFT) 27. + Push Plus (Serr Ant) 28. + Lawn Mower (LFT progression) 29. + Robbery (LFT Progression) 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. (Kibler, 2003) 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):178998. 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):13860. 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):36472. 5. Kibler WB, McMullen J. Scapular dyskinesis and its relation to shoulder pain. J Am Acad Orthop Surg. 2003 Apr;11(2):14251. 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;285:1919. 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):64161. 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):43946. 9. Kibler WB. The role of the scapula in athletic shoulder function. The American Journal of Sports Medicine. 1998;26(2):32537.