Describe methods to evaluate for scapular. Perform a scapular dyskinesis examination. With humeral elevation, the scapula:

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1 Describe methods to evaluate for scapular dyskinesis Perform a scapular dyskinesis examination Lori Michener, PhD, PT, ATC Virginia Commonwealth University Richmond, VA Ant / Post Tilting Internal / External Rotation AC Ant / Post Tilting Upward / Downward Rotation Superior / Inferior Translation Anterior / Posterior Translation With humeral elevation, the scapula: Externally Rotates (24 ), Upwardly Rotates (50 ), and Posteriorly Tilts (30 ) Translates superior and posteriorly, as defined by the position of the scapula via clavicular motion Clavicular elevation (sup translation) & retraction (posterior trans) 1

2 Humeral elevation UR: 50 PT: 30 ER: 24 Ratio of motion btw the humerus & scapula (UR) during shoulder elevation elevation: minimal scapula mov t 30 & above: 2:1 ratio: 2 H: 1 Scap Evidence indicates: Not exactly linear Not symmetrical bilaterally Thoughts. So do these scapular dysfunction lead to the patholgoy? Chicken or the egg? Meaningfulness of these differences are these clinically important??? Can we identify scapular dyskinesis clinically? An observable alteration in scapula position & motion pattern relative to the thorax (Kibler, 2003) No standard system for identifying scapular dyskinesia clinically Limited evidence as to how a scapular Dx or evaluation guides treatment 2

3 7 Test movements (5 reps each) Active and weighted flex (F:3lb / M:5lb) Active and weighted abduction (F:3lb / M:5lb) Wall and plinth push ups with a plus Flip test (resisted ER in neutral) McClure et al 2002 Resisted ER Scapular medial border winging: + test If the scapular ms are not strong, then they cannot stabilize the scapula as the ER ms contract Potential Abnormalities Winging Posterior displacement of inferior angle or medial border Dysrhythmia Lack of normal scapulohumeral rhythm during raising/lowering Must be present during 2 of the 5 reps Kappa = 0.6, 72% agreement 24 31% judged as abnormal Winging occurs when the scapula s medial border and/or inferior angle moves away from the posterior thorax, becoming more prominent during arm motion and a sulcus/gap is created between the scapula and the thorax Picture: Posterior view of winging McClure et al 2002 Picture: Superior view of winging 3

4 Describes a lack of smooth scapulohumeral rhythm A hitch or a jump in the otherwise smooth motion. (Kibler, 2003) Most common pattern is early/excessive scapular elevation (shrug) Another common pattern: rapid downward rotation during lowering (dump) Posterior view Picture: Example of shrug during arm raising Picture: Dumping during arm lowering Symptom Alteration Tests Scapular Reposition Test Scapular Assist Test Grasp scapula with fingers contacting coracoid and/or AC joint and apply a posterior & external rotary and mild retraction force with forearm obliquely contacting scapula toward inferior angle as a counterpressure. Re perform painful mov ts or actions such as: Arm elevation Neer s test Hawkin s test Jobe s test (empty can) Stabilizes the upper scapular border into mild retraction and assists UR of the inferomedial border with the ethumb until manual contact is not further possible. Re perform Arm elevation and look to eliminate painful arc 1. Shoulder pathology 2. Poor posture Tight Pectoralis minor: IR Supine: distance from posterior acromion to table Normal: < 1cm diff 4

5 2. Poor posture T &C spine: ed flex of T or C spine alter scap kinematics ( UR &PT) Postural assessment Acromion lined up with L spine? T spine Kyphosis? C spine Forward head? 3. Posterior Shoulder Tightness Theorized to alter scapular kinematics, particularly in overhead throwers (Myers JB, AJSM, 2006) Test: Stabilize scapula by pushing on the on lateral boarder Horizontally adduction Normal: ~ 95 degrees of add 4. Scapular ms Serratus Ant & Lower Trap activity: associated with impingement & scapular dyskinesis 5. Rotator cuff ms: ER s Fatigue of RC PT, ER, or UR, clavicular retraction (Tsai N, APMR, 2003; Ebaugh D, 2006) Block of suprascapular N. ER & UR (McCully S, Clin Bio, 2006) Highest ms activity: Abd or scapular plane elevation and resist shoulder elevation Resisting protraction: does not elicit as much as SA ms activity Highest ms activity for the LT: MT and LT ms tests produced about the same ms activity (not sig. different from each other) Lower Trap muscle test Highest ms activity for the ER and IR: ER test IR test Middle Trap muscle test 5