Sydney Physiotherapy Solutions

Matt Crawshaw

Blair Chapman

Chantal Wingfield

Today’s Topic is The Scapular

Shoulder pathology

Measuring static and dynamic scapular stabilisation

Using measurements to screen for prevention of shoulder injuries and to identify scapular dysfunction due to injury.

Using measurements to progress rehabilitation.

Today’s Goal

1. Interact and Share

discuss shoulder injuries from the Personal Trainers perspective

discuss shoulder injuries from the physiotherapist perspective

suggest a framework where the Personal Trainers and the Physiotherapists can be a team for the client with a focus on keeping them training with the Personal Trainer through their injury.

2. Develop trust with you

Framework for Physio’s and PT’s to work within

When we receive a patient from a PT with a Shoulder problem 

Our responsibility lies equally between the patient and the PT.

We need to establish a diagnosis and prognosis and communicate that to the patient and the PT.

Framework for Physio’s and PT’s to work within

To reduce Symptoms and address the likely poor scapular stabilising strategy that is present as a reaction to the injury.

To give patient back to PT with minimal Sx and a good scap stabilising strategy for the PT to load that strategy to regain full strength .

Framework for Physio’s and PT’s to work within

Important for the PT to understand how to identify good and bad scap stabilising strategies and to be able to monitor this during strength training.

We need to do this as soon as possible to maintain the relationship between patient and PT. If there is a longer period of rest required for the shoulder we need to provide the PT with safe strengthening exercises to do during the rehab process.

More detail of this Framework

Chantal is going to present the pathologies we are thinking of when a shoulder injury is referred to us from a PT and how we diagnose this.

Blair will describe the current understanding of scap stabilisation and how it is affected by injury. He will run a small practical session on how to measure and identify this for screening your clients before strength training and rehabilitating your clients back into strength training post injury.

Shoulder Pathologies

Fracture

Dislocation 

Muscle tear

Labral tear

ACJ injuries

Frozen shoulder

Arthritis

Subacromial impingement – including tendinitis,

bursitis and postural dysfunctions

Alternative considerations

Cervical spine

Thoracic ring dysfunction

Thoracic outlet syndrom / Brachial plexus

Peripheral neuropathies

Tumors / lung Ca / heart

Dislocation Usually traumatic

Anterior most common

Be aware of the chronically unstable shoulder

Physiotherapy input recommended and usually imagery required as recurrence is highly likely

Surgical stabilisations occasionally required in presence of structural defect EG Bankart, unstable SLAP or Hill Sachs

Muscle tear E.g. Rotator cuff but not

exclusive

Can be traumatic or degenerative

• Usually causes pain upper arm• Often but not always complain of weakness • Needs physio input +/- orthopaedic input depending on extent of tear/dysfunction & duration of symptoms• Diagnosed clinically with use of US or MRI as required• If traumatic, timing is key as better surgical outcomes within 3 months of injury

Labral TearCan be traumatic or degenerative

Can be asymptomatic

Can cause clicking, feelings of instability or deep shoulder ache

Physio input recommended with ongoing PT.

Physio to guide re ex precautions & rehabilitate shoulder stability whilst training

• Occasionally surgical input required if unstable or fail conservative input• Caution with shoulder weight bearing and overhead loading during initial rehab phase

ACJ

Usually managed conservatively

We will grade the injury and guide regarding their rehab and ongoing training

Avoid distraction / loading / weight bearing for ~ 2–6 weeks depending on grade of injury

Important to ensure normal mechanics post injury as can lead to secondary problems such as impingement

Frozen ShoulderAKA ‘Adhesive

Capsulitis’

Inflammation and scarring of your joint capsule

Starts as a painful shoulder and develops into a stiff shoulder

More common in diabetics

• Needs range maintenance exercises and occasionally onward referral for a corticosteriod injection or capsular release

Arthritis

Osteoarthritis is also known as joint ‘wear and tear’

Older population

Stiffness and pain • Need careful grading of exercises, not too high loads as indicative that their cuff and labrum are severely degenerative• Very occasionally referred for shoulder replacement but outcomes currently limited. Good pain responses but ROM and strength outcomes poor so last resort.

Subacromial Impingement – Bursitis / tendinitis

Can occur post trauma, with overuse, sudden increase in training or gradual insidious onset as a result of poor biomechanics• Present with pain during arm elevation at end of

range or often a painful arc and usually HBB also sore

Additional Potential Differentials

Cervical spine

Upper lung lobe

Cervical arteries

Heart

Thoracic outlet / brachial plexus

Peripheral neuropathy

Thoracic ring dysfunction

If unsure, refer to us and we will happily assess and give feedback

We utilise a series of clinical tests, questions and real time ultrasound to establish our diagnosis and then will develop a collaborative management plan with both you and the client

Scapular Mechanics

Scapular Movement

Muscle Actions

Upward Rotation

Serratus anterior, UFT,LFT

Downward Rotation

Levator scapula, Rhomboids,

Pec minor

Anterior/Posterior Tilting

Anterior: Pec minor

Posterior: LFT

Protraction/ Retraction

Protraction: Pec minor, serratus anterior

Retraction: Rhomboids, Trapezius as a whole (latissimus dorsi if humerus fixed)

External Rotation

Serratus anterior

Internal Rotation

Common Presentation

As a result of injury or traumaDownward rotationAnterior tiltMedial rotation

Which muscles are overactive?

Secondary Issues?

Visual Assessment Kibler Classification of Scapular Dysfunction

Type 1 or inferior Dysfunction

Main feature is inferior angle prominence as a result of anterior tilting.

Best seen with hands on hips or eccentric lowering of arms from overhead ( most common in rotator cuff dysfunction)

Type 2 or medial Dysfunction

Prominence of entire medial border of scapula due to internal rotation of scapula.

Best seen with hands on hips, eccentric lowering from overhead

Common in shoulder joint instability

Type 3 or Superior Dysfunction

Excessive and early elevation of the scapula during elevation.

Ie. Shoulder Shrugging.

Often seen in rotator cuff dysfunction and deltoid rotator cuff force coupling imbalances

Studies support validity of visual observation of scapular dyskinesis

Rotator Cuff Function

What is the function of the rotator Cuff?

Relationship with scapulaArm abduction (Lateral raises, military press)

Horizontal adduction (chest press, fly’s)

Shoulder flexion (front raises, boxing)

Observation Examples

Summary

Any questions

?