Scapular function and dysfunction
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1 Scapular function and dysfunction - Impingement - Muscle detachment
2 W. Ben Kibler, MD Medical director
3 FUNCTION
4 IMPINGEMENT REVISITED Is impingement always a diagnosis- isolated description of pathology to base treatment upon- or more likely a syndromemultiple causative factors
5 WHAT IS IT Dr Charles Neer- JBJS 1972 Rotator cuff under acromion, coraco-acromial arch Subacromial alteration Abrasive wear- stages 1,2,3 Anterior acromioplasty
6 EVALUATION Exam-find the impingement positions- painful arc Neer, Hawkins maneuvers Test- eliminate sx- injection X-ray- anatomy- outlet view Diagnosis - impingement
7 TREATMENT Follows exam and tests that make the diagnosis Numb up the space Address acromion/c-a archincrease subacromial space Raise the roof Open vs arthroscopic
8 TREATMENT Non operative Modalities Rotator cuff based exercises to address demonstrated weakness Mobilization- stiffness
9 TREATMENT Operative SAD, +/- DCE Another DCE Other scope- labral, capsular release Pain clinic
10 OUTCOMES Very variable Generally good- early symptom relief Later failures- return of sx Not as good for young throwers, workers %
11 OUTCOMES JBJS(Br) Outcomes from surgery or rehabilitation are the same More cost for surgery Natural history not well understood
12 IMPINGEMENT Frequently is an alteration of normal coupled scapulohumeral rhythm, creating pressure/tension in a confined changeable space with many pain receptors
13 IMPINGEMENT Broader perspective- factors causative for impingement Dx impingement - start of the process, not the end Appropriate treatment based on all factors in diagnosis
14 Scapula/impingement BJSM 2013 Scapular Summit Substantial frequent involvement in symptoms? Cause or effect Altered acromion, sub acromial space, strength
15 IMPINGEMENT 3-D kinematic analysis Decreased posterior tilting significantly (~10 ) Lukasiewicz et al. JOSPT 1999 Ludewig & Cook PT 2000
16 DYSFUNCTION
17 DYSFUNCTION
18 EVALUATION Scapular exam Clinical observation Position Motion- arm motion Corrective maneuvers
19 Corrective maneuvers EVALUATION Scapular Assistance Test Assist scapular upward rotation/posterior tilt (+)- Relief of external impingement symptoms Kibler,W.B. AJSM 26(2): , 1998 Rabin, A. et al, JOSPT 36(9): , 2006
20 SAT Results: Posterior 20 Tilt 15 Posterior Tilt (Degrees) Main Effect: SAT (5 ) > Unassisted (-2 ) p = Unassisted SAT
21 Corrective maneuvers EVALUATION Scapular Retraction Test Assist scapular external rotation/posterior tilt (+)- Inc rot cuff strength, relief- internal impingement Kibler WB, AJSM 1998 Kibler WB, Sciascia AD, Dome DC, American Journal of Sports Medicine, 34(10): , 2006
22
23 Muscle detachment Scapular emphasis MD- previous surgery inc sx I know something s not attached- find out what Surgical exploration- tear? How to fix
24 Muscle detachment More cases over years How to clinically categorize the symptoms, clinical picture, treatment Surgical treatments What are the outcomes
25 Clinical Results from Kibler et al JSES 2014
26 Prospective study Injury mechanism Number (%) MVA 35 (45) Traction/load 19 (24) Athletics 15 (19) Other 9 (12)
27 Prospective study Patient reported complaints Localized medial border scapular pain- 78 (100%) Decreased overhead activity capability- 77 (99) Decreased forward flexion capability- 76 (97)
28 Prospective study Patient reported complaints Headaches/muscle spasms- 67 (86) Decreased flexion strength- 52 (67) Decreased abduction/over head strength- 46 (59)
29 Prospective study Sx duration 51( ) mos 4 (1-20) other physicians 1 (0-6) other surgeries PT 14 (1-42) mos 3 (2 CT, 1 MRI) imaging positive for muscular injury
30 Prospective study Physical exam findings Dyskinesis- 78 (100) Medial border pain- 76 (97) (+) SRT- 76 (97) (+) SAT- 76 (97)
31 Prospective study Physical exam findings Can t raise > (96) Weak rotator cuff- 59 (76) Palpable defect- 47 (60) (+) impingement- 40 (51)
32
33 Prospective study Surgical findings Low trap- 78 (100) Rhomboids- 78 (100) Increased scar- 16 (20) Serratus- 4 (5)
34 Detachment Foot Lower Trapezius Muscle Head Medial Scapular Border Infraspinatus Muscle Scapular Spine
35
36
37 Prospective study ASES scores (N= 78) Intake/Discharge Pain 18/35 P<.0001 Function 20/28 P<.0001 Total 38/63 P<.0001
38 Prospective study 2-3 year ASES scores (N=34) Intake/Discharge/Follow up Pain 20/34/35 P<.0001 Function 19/30/34 P<.0001 Total 39/63/69 P<.0001
39
40 Conclusions Specific clinical syndrome Major activity/life disruption Consistent history, physical exam, sx, dysfunction Imaging not helpful Consistent surgical findings
41 Conclusions More awareness Need to recognize the acute injury and start definitive treatment so that the long term problems don t get established
42 THANK YOU
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