diagnosis and treatment of scapular injuries
TRANSCRIPT
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Thomas A Goodwin DO
Borgess Sports Medicine
Kalamazoo, MI
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Discuss Scapular Injuries
Discuss Scapular
Functional Anatomy
Discuss Scapular
Mechanics
Discuss Rehabilitation of Scapular
Injuries
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Fractures
Direct and Indirect
Clavicle, ribs, etc
Joint Injury
GH/labrum
AC
SC
Muscular Injury
Rotator cuff
Muscular detachment
Functional Disturbance
Scapular Dyskinesis
SICK Scapula
GIRD
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Scapula, Clavicle, Ribs
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• Present in 1% of blunt trauma cases
• 0.4-1% of all bone fractures
• 80-90% with concomitant injuries
• Clavicle fracture (23%) “Floating Shoulder”
• Shoulder dislocation
• Pulmonary Contusion/Pneumothoax (23%)
• Also flail chest and tension pneumo
• Brachial plexus
• Axillary artery injury
• Rib fractures
• CT scan often required to determine severity
http://www.wheelessonline.com/ortho/scapular_fractures
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• Site • Body/Neck
• 2/3 of scapular fractures
• Usually impacted and extraarticular
• Good prognosis
• Surgical Indications
• > 1cm medial displacement
• > 400 angulation
• Glenoid Lip
• Usually associated with dislocation
• Surgery - > 10mm displacement or 25% intraarticular
• Glenoid Fossa
• Uncommon (< 10%). Surgery if > 5mm displacement
http://www.wheelessonline.com/ortho/scapular_fractures
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• Alone
• Disruption often leads to
abnormal protraction of the
scapula
• Floating Shoulder1,2
• Concomitant Scapular
fracture
• Scapular Suspensory System
• Superior(SSSS)
• Lateral (LSSS)
• Ribs
• Often lead to dyskinesis
1. http://www.wheelessonline.com/ortho/floating_shoulder_injuries
2. Lambert S et al. Focussed classification of scapula fractures.Injury 2013. http://dx.doi.org/10.1016/j.injury.2103.03.001
http://www.orthofracs.com/adult/trauma/shoul
der/floating-shoulder.html
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Glenohumeral/labral, Acromioclavicular, Sternoclavicular
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• Multidirectional
instability (MDI)
• Labral Tear
• 15/85
• “Torn loose” vs “Born loose”
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• Multidirectional
instability (MDI)
• Labral Tear
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AC injury
SC injury
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Rotator Cuff, Muscle Detachment
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• Very Broad Term
• Local Problems
• RC, Long head biceps
• Bursitis
• Labral pathology
• Distant Problems
• Scapular dyskinesis
• Kinetic chain disruption
• Chicken or the egg???
• Either way, treat the scapula!
• Impingement
• Rotator Cuff Tears
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• Lower trap and rhomboids • Detach from medial scapular border
• Uniform presentation • Early post-traumatic onset of
localized intense pain along the medial scapular border
• Major limitations in forward flexion or overhead
• Localized tenderness • Palpable soft tissue defect
• Altered scapular resting position • Dynamic dyskinesis
• Positive SRT
• MRI CT not helpful
• PT first but occasional surgery
Scapular Muscle
Detachment
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Scapular Dyskinesis/GIRD/Upper Crossed Syndrome
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• Upward/Downward
Rotation
• Internal/External Rotation
• Anterior/Posterior Tilt
• Upward/Downward Glide
Scapular Motions
In isolation, these are
clinically limited
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• External Rotation
• Posterior Tilt
• Upward Rotation
• Medial Translation
Retraction
• Internal Rotation
• Anterior Tilt
• Downward Rotation
• Lateral Translation
Protraction
• Upward Translation
• Anterior Tilt
• Internal Rotation Shrug
Clinical Implications
Composite, Coupled
Motion
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• Kibler 2001
• “An observable alteration of the position and motion of the scapula relative to the thoracic cage
• “The requirement of high levels of scapular muscle activation to stabilize the scapulothoracic aritculation and optimally position the glenoid to maximize glenohumeral congruity”
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• Scapular malposition
• Inferior medial border
prominence
• Coracoid pain
• Dyskinesis
• Tight pec minor/biceps
• Lowered throwing
shoulder
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• > 20o
• Tight posterior
capsule
• PIGHL
• Leads to “Wind-up”
• Increased protraction
• Kinetic chain disruption
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Swimming:
Dyskinesis/GIRD?
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Throwing Athletes
Overhead Athletes:
Dyskinesis/GIRD?
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Identify Abnormal scapular motion
Determine relations between
dyskinesis and symptoms
Identify causative factors for dyskinesis
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• Evaluate Dyskinesis
• Examine Surrounding Tissues
• Scapular Stabilizer Muscle Testing
• Posture
• Muscle “tightness” evaluation
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• Serratus Anterior
• Upper Trapezius
• Middle/Lower
Trapezius
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• Forward head posture
• Increased thoracic
kyphosis
• Shortened pectoralis
minor
• Posterior shoulder
tightness
• Upper Crossed
Syndrome evaluation
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• Pec Minor
• Posterior Capsule • PIGHL
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Dynamic Scapular
Dyskinesis Tests
LST • Lateral Scapular
Slide Test
SAT • Scapular
Assistance Test
SRT • Scapular
Retraction Test
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• Static Measurement
• ILA Scapula
Spinous Process
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Reduction or
abolition of pain =
positive
http://www.youtube.com/watch?v=I9Dzze57EWM
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http://www.youtube.com/watch?v=Tm_q2ipA0_o
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Type I Type II Type III
Kibler WB, Uhl TL, Jackson JW, Brooks PV, Zeller B, McMullen J: Qualitative clinical evaluation of
scapular dysfunction: A reliability study. J Shoulder Elbow Surg 2002;11:516-27.
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• Laboratory studies with
3D tracking1,2,3
• Gold Standard
• Practicality?
• Clinical inter-rater
reliability questioned 3,5
• Conflicting evidence
1Bourne et al. Three dimensional rotation of the scapula during functional movements. J Shoulder Elbow Surg. 2007;16:150-162 2Konda et al. Scapular rotation to attain the peak shoulder external rotation in tennis serve. Med Sci Sports Exerc. 2010;42:1745-1753 3McClure et al. Direct 3-dimensional measurement of scapular kinematics J Shoulder Elbow Surg. 2001;10:269-277 4Uhl et al. Evaluation of clinical assessment methods for scpular dyskinesis. Arthroscopy. 2009;25:1240-1248 5Ellenbecker et al. Reliability of scapular classification in examination of professional baseball players. Clin Ortho Relat Res. 2012. 470:1540-44
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• LST- Lateral Scapular
Slide Test
• Validity questioned
• Unable to differentiate
between symptomatic
and asymptomatic
shoulders
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• SRT – Scapular Retraction Test
• Validity questioned by Kibler et al 2006 (AJSM) • Found
increased strength regardless of symptoms
http://www.youtube.com/watch?v=Tm_q2ipA0_o
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Evaluation
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• Core
• Planks
• Single leg squat
• Muscle recruitment
patterns
• Hip flexor/Rectus
femoris tension
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Identify causative factors
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Neurologic
•Nerve Palsy (long thoracic/spinal accessory)
Joint Derangement*
•Labral injury
•GH instability
•Biceps tendinitis
•AC separation
Bone*
•Clavicle fractures
•Scapular fractures
Inflexibility
•GIRD
•Total ROM deficits
•Pec minor inflexibility
Muscular
•Lower trap weakness
•Serratus anterior weakess
•Upper trap hyperactivity
•Scapular muscle detachment
Kinetic Chain
•Hip/leg weakness
•Core weakness
*- May need surgical correction before appropriate rehab can begin
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Activation Sequencing
Forced Couple Activation
Concentric/Eccentric Emphasis
Strength Endurance Avoidance of
Unwanted Patterns
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Scapular Clock
Wall Washers
Inferior Glide
Low Row
Lawn Mower
The Robbery
Sleeper Stretch
1Kibler et al. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. Am
J Sports Med 2008;36:1789–98.
Forthomme B, Crielaard JM, Croisier JL. Scapular positioning in athlete's shoulder : particularities, clinical measurements and
implications. Sports Medicine. 2008; 38(5):369-86.
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• Goal is to maximize
MT/LT/SA and minimize
upper trap
• Cools1 De Mey2 protocols
• Change activation patterns
• Validated by De Mey3 2012
• Mild impingement syndrome
• 6 week home rehabilitation
• Significant reduction in pain
with exercise alone
Which Exercises?
1Cools AM et al. Rehabilitation of scapular muscle balance: which exercise to prescribe? AJSM 2007;35(10):1744-1751 2De Mey K et al. Trapezius muscle timing during selected shoulder rehabilitation exercises. JOSPT 2009;39(10):743-752 3De Mey et al. Scapular muscle rehabilitation exercises in overhead athletes with impingement syndromes. AJSM 2012;40(8):1906-1915
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• Intuitively it makes sense
• Evidence?
• Sucher1 found correction of pec minor shortening
• US Measurement
• Case study
• Rosa2 et al found no effect of manipulation on scapular
rhythm
• EMG study
• Asymptomatic patients
• Seated HVLA
1Sucher. Ultrasound-guided OMT for a patient with thoracic outlet syndrome. JAOA. 2011;111:543-547 2Rosa et al. Effect of seated thoracic manipulation on changes in scapular kinematics. J Manipulative Physio ther. 2013;Sep 5. epub
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Dyskinesis present in high percentage of shoulder injuries
Exact role of dyskineis unknown
• Create or exacerbate?
Shoulder impingement
particularly affected by dyskinesis
Dyskinesis viewed as potential
impairment to shoulder function
Recognition of dyskinesis
improves treatment outcome
Reliable clinical evaluation method
for dyskinesia exists
Rehab programs should encompass
correction of dyskinesis