Kevin E Wilk, PT, DPT,FAPTAmedia-ns.mghcpd.org.s3.amazonaws.com/sports2018/... · • Push-ups with...
Transcript of Kevin E Wilk, PT, DPT,FAPTAmedia-ns.mghcpd.org.s3.amazonaws.com/sports2018/... · • Push-ups with...
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Scapula Dyskinesis:Evaluation & Treatment of
the Scapula in Athletes:Kevin E Wilk, PT, DPT,FAPTA
`
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• Scapular Dyskinesis:
Alteration in scapular position or movement
Due to boney or soft tissue lesions
As well as weakness or inflexibility
Kibler & Sciascia: Br J Spts Med ‘10
Scapulothoracic JointIntroduction
Scapular Dyskinesis Test (SDT)
McClure et al: J Athl Train ‘09
2 handheld weights based on body size:< 68.1kg = 3 Ib. weights
>68.1 kg = 5 Ib weights
• Perform 5 bilateral reps of shoulder flexion & then shoulder abduction
• Speed of movement 3 sec ascend/descend
• Videotaped for analysis
• If it looks abnormal – it’s scapular dyskinesis
Scapular EvaluationScapular Dysfunction
Shoulder elevation scapular planeWithout resistance
With resistance
Shoulder abductionWithout resistance
With resistance
Which Motion is Better to Evaluate?
Scapular EvaluationScapular Dysfunction
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Clinical Implications of Scapular Dyskinesis: 2013 Consensus
Kibler et al: BJSM ‘13
• Scapular dyskinesis is present in high percentage of shoulder injuries
• Exact role of scap dyskin in creating or exacerbating shoulder Sx not well defined
• Impingement affected by dyskinesis
• There is a reliable clin exam method available
• Rehab programs including scapular position, motion, & function can be effective
Scapular EvaluationEvaluation Post-Fatigue
Scapular Dyskinesis ClassificationOverview
• Scapular dyskinesis is too vague – not specific enough for differential diagnosis & specific treatment
Classification system Kibler et al: JSES ‘02
I: inferior border pattern
II: medial border pattern
III: superior border pattern
IV: normal scapula
Scapular Dysfunction & Injury Risk in High School Baseball Players
• Pre-season screening of 246 high school players (mean age 16.6 yrs) playing 10yrs
• Assessed scapula using the SDT described by McClure et al: JAT ‘09
• Examined examiners analyzed video (2)
122/246 identified with scapular dysfunction
2/122 in scap dysf grp their shoulder or elbow
10/124 in the normal scap group - injuries
Total of 12 injuries
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Shoulder Examination in Athletes (especially Overhead Athletes is an Entire Body Screening/Examination
• Rubin & Kibler: Arthroscopy ’02
• Burkhart et al: Arthroscopy ’03
• Kibler et al: JOSPT ‘09
• Kibler et al: Br J Sports Med ’12
• Beckett et al: AJSM ‘14
Beckett et al: AJSM ‘14
• Assessment of scapular & hip joint in preadolescent (7-12 yrs) & adolescent (13-18 yrs) in baseball players
Beckett et al: AJSM ‘14
• Assessment of scapular & hip joint in preadolescent (7-12 yrs) & adolescent (13-18 yrs) in baseball players
High rate of scapular dyskinesisin adolescent players compared to pre-adolescent
Also poor single leg squat test
Higher coracoid process distance – correlated dyskinesis
Scapulothoracic Control for Normal GH Motion
Allows the Humerus to above 900
Maintains normal GH relationshipMaintains consistent
length-tension relationship of musclesFollows the humeral headActs as anchor – allows
increased motion
Scapulothoracic JointScapulohumeral Rhythm
0 – 300 setting phase
30 – 900 2 : 1
90 – 1600 1 : 1
Overall ratio 1.7 : 1
Scapular Kinematics
• 3 Rotations» Upward/ Downward
» Internal/External
» Anterior/Posterior
• 3 Translations» Superior/Inferior
» Anterior/Posterior
» Medial/Lateral
McClure JSES ‘01
“Translation”/Position: Superior
Rotation: Upward
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Ant / PostTilting
Internal / ExternalRotation
Up / Down Rotation
Superior/Inferior Translation
Anterior /PosteriorTranslation
Scapular Motion
Scapular Upward Rotation
Up
war
d R
ota
tio
n [
deg
]
10
20
30
40
50
60
70
0 30 60 90 120 150
Humerothoracic SP Elevation [degrees]
Upward
Downward
Mean = 50o (4.8)
(n = 8)
McClure JSES ‘01
Scapular Posterior Tilting
0
10
20
30
40
0 30 60 90 120 150
(n=8)
Humerothoracic SP Elevation [degrees]
Posterior
Anterior
Mean = 30o (13)
McClure JSES ‘01
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Lukasiewicz et al: JOSPT ‘99
• Analyze scapular position and orientation in subject w/ impingement & normals
• 3D electromechanical devices in 3 planes
• During arm elevation: posterior tilting, upward rotation, retraction
Impingement subjects: greater scapula elevation & less posterior tilting
Anterior tilted
Scapula
Posterior tilted
Scapula
Rehabilitation of Shoulder ImpingementRehab Overview:
Specific rehab concepts: pain reduction
restoration ROM& flexibility
normalizing posture
muscular strength (balance)
advanced phases
return to activity phase sports
work activities
Baseball Players - Posture
Borich, Bright, Lorello, et al: JOSPT 36(12) 926-934, 2006
• Scapular angular position assessment at end range internal rotation
• 3- dimensional scapular assessment
• 23 subjects were analyzed
• IR ROM deficit group exhibited significantly greater scapular anterior tilt (9 deg) compared to control group
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Solem - Bertoft: Clin Orthop ‘93
• Used MRI to determine effect of scapular retraction & protraction on acromial space
• Subjects supine & passively positional
Protraction position sign reduced acromial angle, or increased anterior tilting of scapula & decreased SA space
Slouched Thoracic Posture• Shoulder abduction ROM
» Erect: 157.5° (+ 10.8) » Slouched: 133.9° (+ 13.7)
• Abduction strength @ 90°» Erect: 10.4kg (+ 4.5) » Slouched: 8.7kg (+ 3.5)
• Scapular Kinematics • Upward rotation:
» Erect: 43.1° (+7.5) » Slouched: 37.9° (+6.5)
• Posterior tilt » Erect: 44.7° (+6.8) » Slouched: 40.6° (+6.9)
Kebaetse et al. Arch Phy Med Rehab 1999
Lukasiewicz et al: JOSPT ‘99• Analyze scapular position
and orientation in subject w/ impingement & normals
• 3D electromechanical devices in 3 planes
• During arm elevation: posterior tilting, upward rotation, protraction
• Impingement subjects: greater scapula elevation & less posterior tilting*
Assessment of Scapular Position
Kibler et al: Br J Sports Med ’10
McClure et al: J Athl Train ’09
Uhl et al: Arthroscopy ’09
Borich et al: JOSPT ’06
Thomas et al: CORR ‘10
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Scapular Retraction Test
• Perform provocative test » Assess strength of deltoid and
rotator cuff
• Have patient retract scapula and manually provide scapular stability then retest strength
• Improved symptoms (strength) indicates scapular muscular control is compromised
• Supraspinatus strength improved with retraction
Kibler: AJSM ‘06
Scapular Assistance Test
• Assist the scapula retract and upwardly rotate as the arm is elevated
• (+) Pain diminished & range of motion increased
• Indicates improving scapular motion may diminish symptom
Kibler & McMullen JAAOS ‘03
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Bastan, Wilk, Reinold: APTA CSM ‘06
• Analyzed scapular position in 43 professional baseball pitchers
• Assessed 4 static positions» Arm at side
» Full can
» 90 deg abd ER
» 90 deg abd IR
• Compared bilateral differences (T vs NT)
Results: most significant difference was with protraction in all positions, then anterior tilt & more depressed scapula
Macrina, Wilk: CSM ‘07
• Analyzed the effects of fatigue on scapular position in 39 professional baseball pitchers
• Assessed 4 static positions» Arm at side
» Full can
» 90 deg abd ER
» 90 deg abd IR
• Compared bilateral differences (T vs NT)
Results: most significant difference was with protraction in all positions then anterior tilt
Scapular Strength RatiosWilk, Reinold, Hooks…Unpublished data ‘07
Pitchers Non-throwers
D ND D ND
Elev / Depress 400% 480% 520% 540%
Retract / Protract 88% 71% 78% 71%
Scapular Motor Control Re-education
• Visual feedback» Mirror
• Two mirrors positioned at side of patient to view posterior trunk
» Video• Video posterior with the person
watching the monitor
• Do not overly verbal correctUhl & Kibler: ‘06
Scapular Motor Control Re-education
Scapular & Back Across Wall –Feedback & Posture
Scapular Motor Control Re-education – mirror to mirror
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Best Stretch for Pectoralis Minor
Pectoralis Minor Muscle StretchingJ Shoulder Elb Surg ‘06
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pBest Exercises for the
Scapular Muscles
EMG ANALYSIS OF SCAPULAR MUSCLES
Moseley, et al AJSM 1992
• 9 subjects (7males)• Wire EMG electrodes• 8 muscles studied• 16 exercises studied• PRE wt. “could do 10 reps”
EMG ANALYSIS OF SCAPULAR MUSCLES
Moseley, et al AJSM 1992
Four key exercises:
• Scaption ER
• Rowing
• Push-ups with a plus
• Press-ups
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EMG ANALYSIS OF SCAPULAR MUSCLES
Rhomboids: Horizontal ABD, scaption
Serratus Ant. (M): flexion, abduction
Serratus ant. (L): scaption, abduction
Pectoralis minor: press-ups, push-ups +
EMG ANALYSIS OF SCAPULAR MUSCLES
Upper trapezius: Rowing, military press
Middle trap: horizontal Abd (neutral), horizontal Abd (ER)
Lower trap: abduction, rowing
Levator scapula: rowing, horizontal ABD
Ekstrom: JOSPT ‘03• EMG for lower trapezius
» Prone H. abd with ER at 120 –97% MVIC
» Prone ER@90 – 79% MVIC
» Prone H abd with ER at 90
Schachter, McHugh,Tyler, et al: JSES ‘10
• 8 subjects – SEMG and fine wire» Infraspinatus
» Middle trapezius
» Serratus anterior
» Pectoralis major
• EMG activity during ER/IR isokineticsat 60 deg/sec and rowing
During ER/IR - scapular muscle activity occurred
During scapular retraction at 90 deg –rotator cuff activity occurred
“Not isolated movements…” – cuff & scapula relationship
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AJSM ‘08
Kibler, Sciascia, Uhl: AJSM ‘08• EMG analysis of specific
scapular exercises in “early phase” rehab
• Studied: SA, UT, LT, Ant & Post Deltoid
• Performed: low row, inf glide, lawnmower, & robbery exercises
• Moderate EMG activity across all exercises
• SA highest during low row (30%)
• UT & LT were highest during lawnmower & robbery PD > UT, LT (42)
SA > UT, AD (23)
Kibler et al: AJSM ‘08
LT > UT, SA (30) UT > LT, SA (31)
Kibler et al: AJSM ‘08
AJSM ‘08
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Lower Trapezius Exercises !!!
JOSPT ‘09
Reinold, Escamillia, Wilk: JOSPT ‘09
Cools,Witvrouw,et al : AJSM ‘03
• Scapular muscle recruitment patterns (timing)• Compared 39 overhead athletes with shoulder pain
(impingement) to 30 painfree overhead athletes• Performed sEMG to scapular & deltoid muscles –
performed drop arm test Significant slower muscle activation in MT,LT in
painful grp. compared to control grp. (esp. LT)• Painful grp. slower recruitment from deltoid to
trapezius
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Scapular Neuromuscular Exercise
Scapular Muscle TrainingTrain the Scapular Daily
Isotonic table days» Heavier weights
» Isolated movements
» Hypertrophy
» Neuromuscular drills
Scapular Muscle TrainingTrain the Scapular Daily
Isotonic table days» Heavier weights
» Isolated movements
» Hypertrophy
» Neuromuscular drills
Stability Ball days» Lighter weights» Bilateral movts.» Combined movts» Trunk, core, …
Best Exercises for Scapular MusclesLower Trapezius
The Lower Trap exerciseWilk ‘11
Robbery exerciseKibler et al: AJSM ’08
Prone horz abd at 105Ekstrom” 93 Blackburn JAT
“prone full can”Table push down with
depression & retractionWilk: NAJSPT ’06
Inferior Glide Kibler AJSM ‘08
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“Lower Trapezius Exercises”
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Lower Trapezius Stimulation Best Exercises for Scapular MusclesSerratus Anterior
• Push-up with a plusMoseley: AJSM ‘92
• PunchesKendall: ‘79
• Dynamic hugDecker: AJSM’99
Wall slideHardwick: JOSPT ‘06
• Bench press
Decker et al: AJSM 1999
• Ranked the most effective serratus anterior exercises
• 20 subjects performed 8 exercises» Push-up with a plus» Dynamic hug» Serratus punch
Wall Slide (high EMG 90 >)
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Best Exercises for Scapular MusclesMiddle Trapezius - Rhombs
• Prone Horz Abd at 90 palm down
Moseley: AJSM ‘92
• Seated Rowing high handsWilk & Escamilla: JOSPT ‘00
• Prone horz abd at 90 thumb upMoseley: AJSM’92
• Resisted Shoulder AbductionPerry J: Shoulder ‘78
• Reverse Pect. Deck
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Scapulothoracic JointSummary
• Key to shoulder joint function• Intimately involved in shoulder pathology
• Scapular muscle function• Synchronized action• Muscles working in concert
• Scapular motion (normal & pathology)• Understanding abnormal & normal movts
patterns assists in assessment• Think Proximal Stability• “Best exercises for scapular muscles”
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