W.Kibler , John McMullen

J Am Acad Orthop Surg 2003

A JOURNAL ARTICLE REVIEW

ARTICLE INCLUDES

Normal scapular functionScapular DyskinesisMethods of classificationEvaluation techniques

SCAPULAR DYSKINESISIt is defined as observable alterations in the

position of the scapula & the patterns of scapular motion in relation to thoracic cage

The term does not suggest etiology or define patterns that correlate with specific shoulder injuries

Classification of scapular dyskinesis patterns and positions can help to determine treatment

Factors responsibleBony posture or injurycontractures & other flexibility problemsAlteration in muscle function

SCAPULAR EVALUATION SHOULD INCLUDEPostural evaluationResting Scapular EvaluationDynamic Evaluation of scapular motionCorrective measures

SCAPULAR EVAL SHOULD BE DONE FROM POSTERIOR ASPECT

FIRSTLY SCAPULA SHOULD BE EVALUATED IN STATIC POSITION AS IN LONG-STANDING SCAPULAR DYSKINESIS,RESTING WINGING MAY BE SEEN

DYNAMIC EVALUATIONShould be examined in both elevating &

lowering phase of motionMuscle weakness & mild dyskinesis is

commonly seen in lowering phase of arm movement

These commonly present as hitch or jump in otherwise smooth motion of scapula and may be more noticeable with several repetitions

TYPE I PROMINENCE OF INFERIOR MEDIAL SCAPULAR BORDERABNORMAL ROTATION AROUND TRANSVERSE AXISINDICATES WEAKNESS OF LOWER TRAP, LAT DORSI, SERR ANTOR TIGHT PECT MINOR,MAJOR

TYPE IICLASSIC WINGING

PROMINENCE OF ENTIRE MEDIAL SCAPULAR BORDERABNORMALROTATION AROUND VERTICAL AXISINDICATES WEAKNESS OF SERR ANT,RHOMBOIDS,ALL FIBERS OF TRAP

TYPE IIIPROMINENCE OF SUPERIOR MEDIAL SCAPULAR BORDER WITH SUPEROR TRANSLATION OF ENTIRE SCAPULAINDICATES OVERACTIVITY OF LEVATOR SCAPULAE & IMBALANCE OF UPPER & LOWER TRAP FORCE COUPLE

TESTS PERFORMED TO INDICATE WEAKNESS OF SCAPULAR MUSCLES

Isometric scapular pinch testWall push- ups Lateral scapular slide testScapular assistance testScapular retraction test

ISOMETRIC SCAPULAR PINCH TEST

Scapula can be normally held in retraction with isometric pinch for 15 to20 seconds without burning pain or muscle weakness

Scapular ms weakness may manifest as burning pain in less than 15 sec.

WALL PUSH - UPS

Wall push ups are effective for evaluating serratus anterior strength

Abnormalities may be noted with 5 to 10 Wall push –ups

LATERAL SCAPULAR SLIDE TESTInferior – medial angle of scapula is palpated &

marked on both the sidesThe reference point on the spine is nearest

spinous process,which is markedDistance is measured on both the sides in three

different positions,- At resting position With hands on hips, with fingers anterior &thumb

posterior With the arms at 90 degrees with internal rotation

A 1.5 cm asymmetry is the threshold for abnormality

LATERAL SCAPULAR SLIDE TEST

SCAPULAR ASSISTANCE TESTDuring abduction or

forward elevation, assistance is provided by manually stabilizing the scapula and rotating inferior border of scapula as the arm moves

This proc simulates force couple activity of serratus ant and lower trap

Elimination or modification of symptoms indicate these muscles should be major focus in rehab.

SCAPULAR RETRACTION TESTThe examiner

stabilizes the medial scapular border as the arm is elevated or externallyrotated.

Relief of impingement symptoms is a positive test

Guidelines for Integrated Rehabilitation of Scapular Dyskinesis

Exercises Weeks (estimate)Scapular MotionThoracic posture 1-3Trunk flexion/extension/rotation 1-3Lower abdominal/hip extensor 1-5

Muscular FlexibilityMassage 1, 2Modalities (eg, ultrasound, electronic stimulation) 1-3Stretching (eg, active-assisted, passive, PNF) 1-8Corner stretches (pectoralis minor) 1-3Towel roll stretches (pectoralis minor) 1-3Levator scapulae stretches 1-3“Sleeper” position stretches (shoulder ER) 1-3

Closed Kinetic Chain Co-contraction Exercises

Weight-shifting 1, 2Balance board 1, 2Scapular clock 1, 2Rhythmic ball stabilization 2Weight-bearing isometric extension 1, 2Wall push-up 2Table push-up 3-5Modified to prone push-up 5-8

Axially Loaded AROM ExerciseScaption slide 2-5Flexion slide 2-5Abduction glide 3-5Diagonal slides 2-6

Integrated Open Kinetic Chain Exercises

Scapular motion exercices plus arm elevation 3-8Unilateral/bilateral tubing pulls with trunk motion 4-8Modified lawn mower series 3-6Dumbbell punches with stride(progressive height and resistance) 6-8Lunge series with dumbbell reaches 5-8

Plyometric Sport-Specific Exercises

Medicine ball toss and catch 6-10Reciprocal tubing plyometrics 6-10

PRESENTATION ACKNOWLEDGEMENT:

DR. PALLAVI SHIVALKARASSOCIATE PROFESSOR,

DR. D .Y PATIL COLLGE OF PHYSIOTHERAPY

NERUL, NAVI MUMBAI

THANK YOU MADAM…….DR. AJIN JAYAN THOMAS