Mercer County Community College Donna Doulong March 8, 2013

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1 Mercer County Community College Donna Doulong March 8, 2013

2 Why strengthen the scapular muscles? The scapular thoracic articulation is the true core of the upper extremity. (Shankman & Manske, 2011, p. 350)

3 Some background kinesiology Shoulder s glenohumeral (GH) joint one of the most mobile of the body - yet only has the scapula s shallow glenoid fossa as an articulation. Labrum of the glenoid fossa deepens the GH joint. Surrounding ligaments provide further support. (Mansfield, 2009)

4 The scapula also articulates with the thorax via the scapulothoracic joint- merely a junction. Acromion of the superior lateral edge of the scapula articulates with the clavicle via the acromioclavicular (AC) joint. Medial end of the clavicle articulates with the sternum via the sternoclavicular (SC) joint. Active shoulder - further stabilized by musculature, despite lack of bony structural support. (Mansfield, 2009)

5 The heart of the matter. The scapula provides a stable base from which glenohumeral mobility occurs. Voigt & Thomsons, 2000) Scapular musculature makes this possible. Humerus follows the glenoid fossa of the scapula so. There is a scapulohumeral rhythm: for every 2 degrees of glenohumeral abduction, there is 1 degree of upward rotation. This is also true for glenohumeral flexion. (Mansfield, 2009)

6 The scapulothoracic joint coordinates movements with the AC joint and the SC joint. (Mansfield, 2009) If scapular musculature unstable and not efficient in its movements instability of the shoulder follows. (Voigt & Thomson, 2000)

7 We have been learning Stabililization of movement starts proximally. So it is not surprising that scapular stabilization is a regular part of shoulder rehabilitation: First mobility, then stabilization, then controlled movements, then skilled movements. Pain is monitored all along the way.

8 Shoulder Rehab First there is an initial healing procress for injured tissues. Mobility begins with passive range of motion. Scapular stabilization would follow soon after mobility is established. The exercises would be closed kinetic chain. (Shankman & Manske, 2011)

9 Which Muscles? serratus anterior upper, middle, and lower trapezius levator scapula and rhomboid muscles (articulate with thorax) - targeted for strengthening the core of the upper extremities.

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11 The following scapular stabilization exercises were developed by Stephen Burkhart, orthopedic surgeon. NovaCare has a good evidence-based practice and uses them. I highly recommend reading Burkhart s paper on the topic of The SICK Scapula (Scapular malposition, Inferior medial border prominence, Coracoid pain and malposition, and dyskinesis of scapular movement. = (winging, impingement, improper scapular movement) Link: rconceptsburkhart.pdf These exercises are appropriate for the outpatient setting.

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13 How would a more disabled patient follow this protocol? Answer found in Journal of the American Physical Therapy Association - in an article entitled: Clinical Trial Of Exercise for Shoulder Pain in Chronic Spinal Injury (2006). This study was conducted because patients in wheelchairs suffer a lot of shoulder pain.

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15 Assessment Tools (for these exercises) Objective testing to check for efficacy of intervention: Physical therapist makes marks on the back and measures the formation of the scapula distance between the shoulder blades. Done before and after treatment. Goniometry can also be used. FIGURE 5. Scapular abduction is measured with a goniometer on the affected medial scapular margin in reference to vertical midline versus the uninvolved medial scapular margin. (Burkhart, Craig, & Kibler, 2003, p. 644)

16 References Burkhart, S., Morgan, C., Kibler, W. (2003). The disabled throwing shoulder: spectrum of pathology part III: the SICK scapula, scapular dyskinesis, the kinetic chain, and rehabilitation. The Journal of Arthroscopic and Related Surgery, 19, No 6, doi: /S (03)00389-X Mansfield, P. & Neumann, D. (2009). Essentials of kinesiology for the physical therapist assistant. St.Louis, MO: Mosby Elsevier. Nawoczenski, D., Ritter-Soronen, J., Wilson, C., Howe, B., Ludewig, P. (2006) Clinical trial of exercise for shoulder pain in chronic spinal injury. Journal of the American Physical Therapy Association, 86: doi: /ptj Shankman, G. & Manske, R. (2011). Fundamental orthopedic management for the physical therapist assistant (3 rd ed.). St. Louis, MO: Elsevier Mosby. Voight, M. & Thomson, B. (2000). The role of the scapula in the rehabilitation of shoulder injuries. Journal of Athletic Training, 35, Retrieved from