scapular dyskinesis
DESCRIPTION
physiotherapyTRANSCRIPT
Munaf MewafaroshPhysiotherapist
Al-Jahra Hospital
Shoulder ComplexShoulder Complex
Sternoclavicular JointSternoclavicular Joint
Acromioclavicular JointAcromioclavicular Joint
Glenohumeral JointGlenohumeral Joint
Scapulothoracic JointScapulothoracic Joint
Scapulothoracic JointScapulothoracic Joint
Scapulothoracic JointScapulothoracic Joint
(Protraction)(Protraction)(Retraction)(Retraction)
Scapular Rest PositionScapular Rest Position
Scapula Elevation and Depression
Superior trapeziusLevator scapulaeRhomboids
Pectoralis minorInferior trapeziusSerratus anterior Ant part
Scapula Retraction and Protraction
RhomboidsMiddle trapeziusLatissimus dorsi
Pectoralis minorSerratus anterior
Scapula Upward rotation and Downward rotation
Superior trapeziusInferior trapeziusSerratus anterior (Inferior part)
Pectoralis minorLevator ScapulaeRhomboidsLatissimus dorsi
Scapula Stability One of the primary functions of the
scapulae is to provide a stable base from which to create movement in the upper body
The shoulder is a complex joint with
multiple articulations (between the spine, scapulae and humerus) During movement of the arm, a set process known as ‘Scapulo-humeral rhythm' occurs
Scapulo-Humeral Rhythm Scapulo-humeral rhythm serves at
least two purposes
Preservation of the length-tension relationships of the glenohumeral muscles
It prevents impingement between the humerus and the acromion
What is Scapular Dyskinesis? Alteration in the normal static or
dynamic position or motion of the scapula during coupled scapulohumeralmovement
It may be due to alterations in bony stabilisers, muscle activation patterns or lack of strength in the dynamic muscle stabilisers. (Kibler, 1998)
Other names given to this catch-all phrase include: “floating scapula” and “lateral scapular slide”
When describing the static position of the scapula, if an asymmetry is observed, then this should be referred to as ‘altered scapular resting position’ rather than scapular dyskinesis (Kibler & Sciascia, 2010)
Alterations in scapular position and motion occur in 68 – 100% of patients with shoulder injuries
Kibler’s Classification Of Scapular Dyskinesis
Prominence Of Inferior Medial Scapular Border
Abnormal Rotation Around Transverse Axis
Indicates Weakness Of Lower Trap, Lat Dorsi, Serratus anterior Or
Tight Pect Minor,major
TYPE 1
TYPE 2 Classic Winging
Prominence of entire medial Scapular border
Abnormal rotation around vertical axis
Indicates weakness of Serr ant,rhomboids,all fibers of trapezius
TYPE 3 Prominence Of Superior Medial Scapular Border With Superior Translation Of Entire Scapula
Indicates Overactivity Of Levator Scapulae & Imbalance Of Upper & Lower Trap Force Couple
Postural abnormality or anatomical disruption
Nerve Injury
Lack of muscular / capsular flexibility or contracture
Muscle imbalance or weakness
Proprioceptive Dysfunction
Tests for Scapular Dyskinesis Scapular Retraction Test (SRT)
Scapular Assistance Test (SAT)
Lennie Test
Lateral Scapular Slide Test
Wall push- ups
Flip Test
Scapular Retraction Test (SRT)
Scapula can be normally held in retraction with isometric pinch for 15 to20 seconds without burning pain or muscle weakness
Scapular muscle weakness may manifest as inability to maintain a sustained contraction along with burning pain in less than 15 sec (Rhomboids)
Scapular Assistance Test (SAT)During abduction or forward
elevation, assistance is provided by manually stabilizing the scapula and rotating inferior medial border of scapula
This process simulates force couple activity of serratus anterior and lower trapezius
Elimination or modification of impingement symptoms indicate a positive test
Lennie Test Compare scapular
measurements at 3 positions
1. T2 (superior angle)
2. T4 (scapular spine)
3. T7 or T8 (inferior angle)
Lateral Scapular Slide Test Inferior – medial angle of scapula is palpated &
marked on both the sides The reference point on the spine is nearest spinous
process, which is marked Distance is measured on both the sides in three
different positions -A. At resting positionB. With hands on hips, with fingers anterior
&thumb posteriorC. With the arms at 90 degrees with internal
rotation A 1.5 cm asymmetry is the threshold for abnormality
Wall Push – Ups Test Wall push ups are
effective for evaluating serratus anterior strength
Abnormalities may be noted with 5 to 10 Wall push –ups
Flip Test Resisted External
rotation - Scapular medial border Winging indicates a Positive test
Indicates Scapular muscle weakness
Pectoralis Minor Tightness
Supine : Distance from posterior acromion to table
Normal : < 1cm Difference
Effect of Scapula Repositioning TestResearch Report - JOSPT, January 2008,
Volume 38
Study Design : Two-group, repeated measures design
Objectives : To determine whether manually repositioning the scapula using the Scapula Reposition Test (SRT) reduces pain and increases shoulder elevation strength
Methods & Measures : 142 college athletes underwent testing for clinical signs of Shoulder impingement. Tests provoking symptoms were repeated with the scapula manually repositioned in to greater retraction and posterior tilt
A numeric rating scale and a dynamometer were used to measure symptom intensity and Isometric shoulder elevation strength respectively
Results : Of the 98 athletes with a positive impingement test, 46 had reduced pain with scapular repositioning
Repositioning produced an increase in strength in both the impingement (P = 0.001) & nonimpingement groups (P = 0.012) a significant increase in strength was found with repositioning in 26% of athletes with and 29% of athletes without positive signs for shoulder impingement
Conclusion : The SRT is a simple clinical test that may potentially be useful in an impairment based classification approach to shoulder problems
Implication : The SRT may be a way to identify people most suitable for interventions addressing the scapula, such as strengthening, taping or bracing
Limitation : This study only assessed over head athletes who were either asymptomatic or whose symptoms did not cause them to seek medical care, therefore, direct extrapolation of these results to a patient population is not possible
Pain relief modalities
Correct Postural dysfunction
Avoid painful UE movements & Fatigue of the scapulohumeral / thoracic muscles
Soft tissue or Joint Mobilization (if indicated)
PNF patterns for hip and trunk muscles Trunk extension + lateral rotation
facilitates scapular retraction
Trunk flexion + medial rotation facilitates scapular protraction
Regain proximal scapular control & strength before loading the rotator cuff
CKC OKC Exercises
Scapular Clock at 12 & 6
Elevate and depress the scapula with fingers pointed up towards the 12 and 6 o’clock positions
Scapular Clock at 9 o’clock
Retract and protract the scapula with fingers pointed in to 9 o’clock position
Scapular Clock at 3 o’clock
Retract and protract the scapula with fingers pointed in to 3 o’clock position
Low Row Extend the
trunk, pushing the hand forcefully against the edge while simultaneously retracting and depressing the scapula for 5 seconds repeated 10 times
CKC Scapular Motion
Wall Washes
Theraband Neutral Shoulder
Theraband Scapular Adduction
Theraband Scapular Adduction with Shoulder ER
Theraband Prone on Elbows Shoulder ER
Serratus Anterior with Theraband
Subscapularis with Theraband
The Lawnmower
The Robbery
Recovery Phase (3 – 8 weeks)
Begin with isometric active assistive concentric eccentric contractions
Begin kinetic chain tubing exercises PNF D2 pattern
Finger Ladder
Wand / Cane exercises
Blackburn exercises
Serratus anterior punch/press
Side Lying Shoulder ER
Shoulder Abduction/Flexion with DB
Scapular Adduction with Depression
Prone Lower Trapezius (Super Man)
Plank
Maintenance Phase (6 – 10 weeks) Must have good scapular control and motion
throughout range of shoulder motion for this phase
Combine OKC UE exercises with LE and trunk mass movement patterns
Rhythmic stabilization of rotator cuff muscles
Eccentric lowering activities against finger ladder
Plyometrics with medicine ball
Scapular retraction depression with Theraband
Trapezius Exercises
Seated / Chair Push-ups / Dips
Bent – Over Row with DB
Lat Pull down
Plyometrics with Medicine Ball