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MSI Scapular Diagnoses Lecture HandoutAdvanced Upper Quarter Course

October 2014

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Diagnosis and Treatment of Movement System Impairment

Syndromes of the Shoulder:Scapular Diagnoses

Shirley Sahrmann, PhD, PT, FAPTAand Associates

Developed by:Cheryl Caldwell, PT, DPT, CHT

Program in Physical Therapy

AssociatesClinical Emphasis:• Nancy Bloom, PT, DPT,

MSOT• Cheryl Caldwell, PT,DPT,

CHT• Suzy Cornbleet, PT, DPT• Debbie Fleming-McDonnell,

PT, DPT• Mary Hastings, PT, DPT,

ATC• Greg Holtzman, PT, DPT• Renee Ivens, PT, DPT• Mary Kate McDonnell, PT,

DPT, OCS• Tracy Spitznagle, PT, DPT,

WCS

Research Emphasis• Linda Van Dillen, PT, PhD• Barbara Norton, PT, PhD• Cara Lewis, PT, PhD• Sara Gambatto, PT, PhD• Sara Scholtes, DPT, PhD• Marcie Harris Hayes, PT,

DPT, OCS


BackgroundOur assumption is that subtledeviations in the precision of scapular and glenohumeralmovement are the cause of

the tissue injury.

In cases of trauma, alterations of normal movement will perpetuate the pain.


Background

• We developed a set of movement-related diagnoses for shoulder problems and a movement examination for assessing the patient’s preferred alignment and movements.


Movement Examination The purpose of the exam is to determine:

• the diagnosis (identify the Movement System Impairment – MSI-syndrome) and

• the contributing factors


Movement ExaminationConsists of:• tests of alignment and movement

performed in a variety of positions: • standing, supine, prone,

quadruped and sitting

• analysis of functional activities

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copyright Washington Universitiy School of Medicine - Pgm in PT Sahrmann & Associates


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Movement Examination• During the examination, the patient’s

preferred alignment and movements are analyzed to determine their effect on the chief complaint.

• The preferred pattern is followed immediately by a secondary test modifying the movement to determine the effect on the chief complaint

Kibler WB et al. Scapular summit 2009 support idea of secondary test


Secondary Tests• Scapular reposition test (SRT)

• SRT performed during Neer, Hawkins and Jobe impingement tests

• Found 46/98 had decreased pain with SRT

• Found increased strength in normalsand impingement group

Tate AT, McClure PW, Kareha S, Irwin D.. J OrthopSports Phys Ther 2008.


Secondary Test• MSI recommendation:

• Use manual assistance to• Align the scapula • Get the scapula to move correctly• Time the movement of the scapula with the

humerus• While moving scapula note the stiffness

encountered (resistance to correction) and in which direction the most stiffness is felt.

• More efficient than correcting one scapular movement at a time.


Movement Examination• The findings from this

examination lead to the assignment of a movement system impairment (MSI) syndrome.


Movement ExaminationTo date, whether the movement

impairment is the cause of tissue injury is unknown but if during the exam, correcting the movement impairment immediately alleviates the symptoms, then treatment may be most effectively directed by a movement diagnosis

Ludewig PM et al 2009; Kibler WB et all 2013


MSI Scapular SyndromesInternal rotation (AC joint)• With anterior tilt (AC joint)• With insufficient UR (SC & AC joint)• With abduction (SC joint)

Depression (SC joint)• With insufficient UR (SC & AC joint)

External rotation/adduction (SC & AC joint)• With insufficient UR (SC & AC joint)

Winging (pathological) (AC joint)

Elevation (SC joint)




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Scapular and Humeral Diagnoses• Both a scapular & humeral diagnosis can be

assigned, if appropriate


Scapular Dyskinesia

Our interpretation:• Scapular internal rotation, anterior tilt, and downward

rotation particularly on the return• Can better address dyskinesia by correcting the

specific scapular movements


SCAPULAR MOVEMENTS AND ALIGNMENT


Scapular Motion• Scapular motion occurs because of

joint motions at the AC and SC joints.


Definitions of Scapular Movements• Adduction (clavicular retraction-SC):

• the scapula translates medially along the rib cage toward the vertebral column.

• Abduction: (clavicular protraction-SC)• translates laterally

• During these motions there is associated scapular internal or external rotation occurring at the AC joint.


Definitions of Scapular Movements• Elevation:(clavicular elevation-SC)

• a movement in which the scapula translates along the ribcage in a cranial direction.

• Depression: (clavicular depression-SC)• translates in a caudal direction.




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Definitions of Scapular Movements• Upward rotation (lateral rotation):

• AC joint• a movement of the scapula about an

axis perpendicular to the plane of scapula

• inferior angle moves laterally• glenoid fossa rotates to face cranially.

• SC joint • posterior axial rotation of clavicle also

contributes to UR.

• Downward rotation (medial rotation):• inferior angle moves medially• glenoid fossa rotates to face caudally.

Ludewig PM et al. 2009


Definitions of Scapular Movements• Anterior tilt/tipping:

• AC joint• a movement of the scapula about an

axis parallel to the scapular spine• coracoid moves anteriorly and caudally • inferior angle moves posteriorly and

cranially.• Posterior tilt/tipping:

• coracoid moves posteriorly and cranially • inferior angle moves anteriorly and

caudally.Ludewig PM et al. 2009


Definitions of Scapular Movements• Internal rotation:

• AC joint• rotation of the scapula about a

vertical axis• lateral border of the scapula moves

anteromedially• vertebral border moves

posterolaterally such that • the costal surface of the scapula

faces more toward the midline of the body

• SC joint • Clavicular protraction also results in

scapular IR

• External rotation:• lateral border of the scapula moves

posterolaterally• vertebral border moves anteromedially

Ludewig PM et al. 2009


Definition of Scapular Movements

• Winging:• AC Joint

• abnormal movement of the scapula about a vertical axis

• vertebral border moves in a posterior and lateral direction away from the ribcage (Hall, CM, Brody LT.)


Summary - Scapular Motions• Upward rotation:

• Primarily from the SC joint via posterior axial rotation of the clavicle on the sternum

• Secondarily from the AC joint • Minimal from elevation at the SC joint

• Posterior tilt:• Primarily from the AC joint

• External rotation:• SC joint (clavicular retraction)• AC joint

Ludewig PM 2009Program in Physical Therapy

Normal Movement at the AC and SC Joints (Ludewig PM. JBJS; 2009)

Bone Pin study with 12 subjects• During arm elevation 0-120°

• SC joint: • Retraction-16°• Elevation-6°• Posterior axial rotation-31°

• AC joint: • UR-11°• IR-8°• Post tilt-19°




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Scapular Motion: Keep in Mind• The AC and SC joints move continuously

throughout arm elevation Ludewig PM 2009

• Clinically we assess scapulothoracic movement into greater ranges of arm elevation than have been studied to date so the values for normal ranges of motion at the AC and SC joints may really be higher than reported so far.


Normal Scapular Motion During Arm Elevation

• Scapula upwardly rotates and posteriorly tilts• Ludewig PM et. al., JOSPT 1996, 2009• Kibler JOSPT 2009• Lukasiewicz AC et. al., JOSPT 1999• McClure PW et. al., J Shoulder Elbow Surg

2001


Normal Scapular Motion During Arm Elevation• Scapula externally rotates especially at

the end ranges. Ludewig PM 2009

• Scapula internally rotates until after ~125° and then starts to externally rotate Braman JP 2009

• By the end of arm elevation the scapula ER so it is 10-20 degrees anterior to the frontal plane.


Normal Scapular Motion During Arm Elevation

• Scapula should elevate but only slightly (6-10°) Ludewig PM 2009

• Vertebral border of scapula should remain in contact with thorax

• Normal GH:ST rhythm: • 2.1:1for abduction; 2.4:1 for flexion; 2.2:1

for scapular plane abduction Ludewig PM 2009


Clinical Assessment: Criteria for Normal Scapular Motion

• By the end range of arm elevation:• Acromion should be aligned with C6-7• Root of spine of scapula should be aligned with T3• The vertebral border of the scapula should reach 55-60

(+ or - 5) . • Normal scapular abduction is 7.5 cm (3”) from the

vertebral spine to the root of the spine of the scapula. • Scapula should posteriorly tilt 10 Ludewig PM 2009• Scapula should externally rotate so it is 10-20 anterior

to the frontal plane Ludewig PM 2009


Normal Scapular Motion During Arm Lowering

• You shouldn’t see increased anterior tilting during arm lowering

• No prominence of vertebral border • Scapula had greater posterior tilting (2°)

during arm lowering compared to arm raising Ludewig PM 2009




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Normal Scapular Motion During Arm Lowering

Arm lowering• There should be decreased

scapular relative to GH movement during arm lowering compared to arm raising

Braman JP 2009


SCAPULAR ALIGNMENT IMPAIRMENTS ANDMUSCLE ACTIONS IMPAIRMENTS


Scapular Alignment and Movement Impairments

Impaired scapular motion can• decrease the subacromial space (Kibler WB 1998,

Ludewig PM et al 2000, Michener LA 2003, Solem-Bertoft E et al 1993), Kalra N 2010, Silva RT 2010.

• decreased upward rotation (Solem-Bertoft E 1993 and Matsen FA 1990)

• contribute to instability of the GHJ (McMahon PJ 1996, Ozaki J, 1989, Ogston JB and Ludewig PM , Am J Sport Med 2007)

Impaired scapular alignment can• contribute to TOS (Ide J, 2003; Nakatsuchi Y 1995, Swift TR

1984)

“Cause” versus “Source”


Scapular Diagnoses: SymptomsAny of the scapular diagnoses can be associated with:

• Impingement symptoms: • GHJ pain, worse with overhead motions or lying on

involved side• Thoracic outlet syndrome:

• paraesthesia or weakness in the arm; pain in scapula, arm or hand

• Instability: • c/o clunking or sensation of shoulder slipping out of

socket• Cervical pain• May be associated with thoracic pain


Key ConceptFor Most Effective Treatment:

• Identify the Principal Movement System Impairment (PMSI) that is consistently associated with the patient’s symptoms throughout the examination (= Diagnosis or Syndrome)

• Identify the impairments that contribute to the Principal Movement System Impairment:• Muscle: (atrophy, strain, length-associated

weakness, increased or decreased stiffness, changes in length)

• Muscle activation: (timing, increased, decreased)

• Biomechanical: (alterations in forces on the joints, bones, structural variations)


For Most Effective Treatment• Focus on modification of the

Principal Movement System Impairment via:• Patient education and practicing

modifying the PMSI during daily activities

• HEP addressing the impairments that contribute to the PMI




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Evidence for Scapular Movement Impairments - Impingement• Decreased scapular posterior tilting

• Lukasiewicz AC et al, JOSPT 1999• Ludewig PM & Cook TM, Phys Therapy 2000• Hebert LJ et al, Arch Phys Med Rehabil,2002• Endo K et al, J Orthop Sci 2001• Lin JJ et al 2006

• Decreased scapular upward rotation• Ludewig PM & Cook TM, Phys Ther 2000• Endo K et al, J Orthop Sci 2001• Lin et al 2006• Lawrence RL 2014

• Increased scapular internal rotation• Warner JP et al, Clin Orthop 1992• Ludewig PM & Cook TM, Phys Ther 2000


Key Point• Variability in scapular movement

impairments may support the importance of basing treatment on the exam findings or movement patterns of the individual patient instead of on the pathoanatomicdiagnosis.

• Diagnosis based on Movement may guide treatment more specifically than a pathoanatomical diagnosis


Evidence for Scapular Movement Impairments - Multidirectional Instability

• Decreased scapular upward rotation and increased scapular internal rotation• Ogston JB, Ludewig PM. Differences in 3-

dimensional shoulder kinematics between persons with multidirectional instability and asymptomatic controls. Am J of Sports Med 2007;35(8):1361-1370


MUSCLE ACTIONS


Torque capabilities of Trapezius (Fey AJ, …..Ludewig PM JOSPT Jan 2007 Abstract)

• Used 3-D motion analysis and computer modeling of muscle moment arms• Findings of Primary Torque Capability:

• Upper trap = clavicular elevation• Middle trap = scapular external rotation• Lower trap = scapular external rotation

and upward rotation • Serratus anterior = upward rotation,

posterior tilt and external rotation


Muscle Activity• There is evidence to suggest that in

patients with shoulder pain muscle activity is altered compared to normal.

• So….during the MSI movement examination, watch for alterations in the normal pattern of muscle activity

Scovazzo ML 1991, Ludewig PM 2000, Cools AM 2003




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Evidence for Changes in Muscle Recruitment - Impingement

• Decreased serratus anterior and increased upper trapezius activity in symptomatic group (EMG)

• Scovazzo ML et al, Am J Sports Med, 1991 (serratus ant)• Ludewig PM & Cook TM, Phys Ther 2000

• with 4.6 lb load EMG @ 60-90 and 90-120º in symptomatic group (upper trap)

• serratus anterior decreased activity across all loads and phases

• Increased lower trapezius activity in symptomatic group

• Ludewig PM & Cook TM, Phys Ther 2000

• Increased latency of response in symptomatic group of middle and lower trapezius muscles

• Cools AM, American Journal of Sports Med 2003


Muscle Length & Movement• There is some evidence to suggest that

alterations in muscle length are correlated with alterations in movement patterns. Borstad JD 2005

• So…..assessing muscle length in the MSI movement exam provides information regarding the contributing factors to movement impairments.


Evidence: Correlation Between Alignment and Muscle Length -Impingement

• Borstad JD & Ludewig PM JOSPT 2005

• subjects with short pec minor resting length show greater anterior tilting during humeral elevation compared to subjects with long pec minor resting length


Effect of Short Pectoralis Major on Adjacent Region - rib cage


WHAT MUSCLES INTERNALLY ROTATE THE SCAPULA?


Scapular Internal Rotators• Posterior deltoid• Teres major• Teres minor• Infraspinatus• Pectoralis Minor (Ludewig PM)




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SCAPULAR INTERNAL ROTATION WITH ANTERIOR TILT


Scapular Internal Rotation With Anterior TiltInternal rotation (AC joint)• With anterior tilt (AC joint)• With insufficient UR (SC & AC joint)• With abduction (SC joint)Depression (SC joint)• With insufficient UR (SC & AC joint)External rotation/adduction (SC & AC joint)• With insufficient UR (SC & AC joint)Winging (AC joint)

Elevation (SC joint)


Scapular Internal Rotation Primary movement impairment isscapular internal rotation which occurs

• with scapular anterior tilt, • abduction, • insufficient upward rotation • either individually or combined.


Scapular Internal Rotation (AC joint) With Anterior Tilt

Movement impairments1. Insufficient scapular external rotation and

posterior tilt at the end range of arm elevation (Ludewig PM 2000 and Lukasiewicz AC 1999, Hebert LJ 2002)

2. Scapular internal rotation and anterior tilt on the return from arm elevation or during early arm elevation due to an issue with patterns of muscle activation

Serratus Anterior is key


Scapular Internal Rotation with Anterior Tilt - End range

What do you see at end range? Excessive scapular IR May not see anterior tilt

What should you see? 10 degrees posterior tilt 10-20 degrees scapular ER (Ludewig PM)


Scapular Internal Rotation




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Anterior Tilt at Rest and Insufficient External Rotation - End range



• Secondary test:• Passively or actively increasing scapular external

rotation and posterior tilt at end range arm elevation decreases symptoms.


Scapular Internal Rotation with Anterior Tilt - Muscle activation

• During the Motion what do you see?• Excessive scapular IR and anterior tilt• May see tilt earlier in the range



• Movement Impairments when there is a muscle activation problem• These patients usually have a combination of IR and

tilting



• Movement Impairments when there is a muscle activation problem

• These patients usually have a combination of IR and tilting



• Secondary test:• correction by verbal and manual cues to dissociate GH from ST motion decreases symptoms




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Scapular Internal Rotation with Anterior Tilt - scapulohumeral muscle control > axioscapular muscles


Axioscapular Muscle Control > Scapulohumeral


Scapular IR with Ant. Tilting: return from Flexion(strength 3/5 on MMT)(muscle activation problem)


Alignment Impairments

• Scapular Internal Rotation:• Scapula > 30 to 40

degrees anterior to frontal plane at rest

• Scapular AnteriorTilting or Tipping:• Prominence of inferior

angle of scapula • Criteria: >10-15

anterior tilt at rest = abnormal Ludewig PM


Structural Variations in Rib Cage with Scapular Internal vs. External Rotation

Structural considerationsHeavy or long armsThoracic kyphosisShape of rib cage/thorax


Evidence: Relationship of Adjacent Region –Thoracic Spine Alignment to Scapular and Humeral Movement

• Decreased scapular internal rotation in a thoracic extended posture vs. thoracic flexion or neutral spine

• Humeral elevation decreased in thoracic flexed postures

Hassett DR…….Ludewig PM. JOSPT, Jan 2007 Abstract (bone pin study)




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Muscle Length and Stiffness Impairments -Scapular IR with AT

• Shortness or stiffness of pectoralis minor may contribute to decreased scapular posterior tilt (Borstad JD 2005)

• Insufficient stiffness of serratus anterior, rhomboids, lower and middle trapezius

• Barindelli G – cadaver study


Muscle Activation Impairments - Scapular IR with AT• Impairment in the timing of activity:

• SH muscles do not elongate as rapidly as axioscapular muscles.

• Pull of SH muscles on scapula > pull of axioscapular muscles on scapula

• Excessive activation• SH: infraspinatus, teres minor, teres major,

posterior deltoid • Insufficient activation

• Serratus anterior, lower, and middle trapezius • Not weakness of serratus – concentric performance

should be better than eccentric


Scapular IR and AT - Intervention

• Increase stiffness of posterior axioscapular muscles• Improve activation and hypertrophy

• Stretch• SH muscles while maintaining scapular position• Pectoralis minor

• Dissociating GH from ST motion• Letting go with SH muscles


Scapular Internal Rotation with Anterior Tilt (end range)

• standing with back to wall - shoulder abduction with lateral rotation to work middle trap at shortened length/increase stiffness; stretch pectoralis major

• shoulder flexion with back to wall once patient able to control scapula to increase stretch on SH muscles

Intervention Exercises



Intervention:• Facing wall shoulder flexion with arm lift

(external rotation and posterior tilt at end range)• Increasing activation and relative

stiffness of serratus anterior and lower trapezius. Serratus anterior is key!

• Maintain correct head alignment• May need to limit ROM initially

• *May contribute to scapular internal rotation by reaching toward wall.


Scapular Internal Rotation with Anterior Tilt -End range

• Intervention: Exercises• Shoulder flexion facing

the wall with arm lift at end

• During lifting arms off wall, focus has to be on scapular movement, not on GH movement




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Scapular Internal Rotation with Anterior Tilt - End Range

Intervention: Stretch Pectoralis Minor nor


Evidence Related To Stretching Exercises For Pectoralis Minor

1. Unilateral self-stretch in standing - best2. Supine manual stretch with towel roll under thoracic spine3. Manual stretch performed in sitting Borstad JD 2006

No monitoring of humeral head in any of these stretches.

1 2 3



• Assessing pectoralis minor• Lewis JS, Valentine RE. 2007 and Borstad JD 2006

question the validity of the supine pec minor length test.

• Based on Lewis JS et al 2007 1” from table may not be correct. They found 5.9-6.3 cm in asymptomatic subjects.

• Linear measurement from origin to insertion of pecminor may be better.


Scapular Internal Rotation with Anterior Tilt - End Range

Intervention exercises:• stretch SH mm. and

posterior capsulesupine horizontal

adduction (McClure P et al JOSPT 2007)

• Can also be done with shoulder in LR

• supine medial rotation


How Long Will Treatment Take?• Changes in muscle length and stiffness

may take longer. Factors to consider: 1. No resistance from antagonist2. Increased stiffness of antagonist3. Shortness of antagonist

• Muscle activation can be changed more quickly.


How Long Will Treatment Take?• Correcting muscle shortness will take

longer than correcting muscle activation impairment.

• Will need to limit end range ROM initially




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Evidence for Relationship Between Anterior Tilt and Decreased Shoulder MR

• Borich MR, Bright JM, Lorello DJ, Cieminski CJ, Buisman T, Ludewig PM. J Orthop Sports Phys Ther 2006;36(12):926-934.

• Scapular angle positioning at end range internal rotation in cases of glenohumeral internal rotation deficit.



Emphasis of Intervention:• Dissociating SH from ST motion

(changing the pattern of muscle activation)

• Maintain correct alignment of the scapula during arm motions



Intervention: Exercises• Facing wall shoulder flexion (dissociation of GH

from ST motion)• Cue to “let go” of SH mm at GHJ

• Cue to “lower elbow” or “let elbow bend”• Avoid initiating return with scapular movement

• “control” the scapular movement with the axioscapular muscles



Improve performance of serratus anterior



Intervention: Exercises cont.• Serratus anterior activation and

strengthening• Quadruped and standing shoulder flex

• Lower and middle trapezius activation and strengthening:• sidelying, standing, prone

• Pec. minor stretching• Stretch SH muscles



Intervention: Quadruped Rocking Backward

Improve performance of serratus anteriorElongation posterior scapulo-humeral




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Intervention: Prone shoulder flexion



Intervention: Sidelying Shoulder Flexion



• Intervention: FunctionReaching Bend elbow to shorten lever arm

Weight lifting Decrease weight untilscapular muscles can maintain correct scapular alignment throughout motion.



GHJ extension contributes to scapular anterior tilt


SCAPULAR INTERNAL ROTATION WITH INSUFFICIENT UPWARD ROTATION


Scapular Internal Rotation with Insufficient Upward Rotation• Internal Rotation

• With anterior tilt• With insufficient upward rotation• With abduction

• Depression• With insufficient UR (SC & AC joint)

• External Rotation/adduction • With insufficient UR (SC & AC joint)

• Winging• Elevation




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Scapular Internal Rotation with Insufficient Upward Rotation

• The movement impairment can happen anywhere in the ROM.• Serratus anterior

is the best upward rotator


Scapular Internal Rotation with Insufficient Upward RotationMovement Impairment• Scapular internal rotation may occur with

insufficient scapular upward rotation during flexion and abduction • Criteria at the end range of shoulder flexion

or abduction = 60 plus or minus 5 of scapular upward rotation

• normal SH rhythm is 60º of scapular upward rotation (Inman VT, 1934)

• scapula downwardly rotates during arm rotation or when a load is placed on the arm


Insufficient Scapular Upward RotationSymptoms• If pain is along vertebral border of scapula, the

source of the pain is usually the cervical spine.• May have pain in the area of the rhomboid

muscleActivities• New mothers• String instrument musicians• Weightlifters, heavy laborers, waitresses, jobs

that require arm to be sustained in flexion• Sit with keyboard or arm rests too low


Scapular Internal Rotation with tilt and Insufficient Upward Rotation

•Insufficient scapular upward rotation duringabduction

• Right (involved) shoulder lower• Right acromion is low • Scapula is downwardly rotatedor depressed



8-15-06


Scapular Internal Rotation with tilt and Insufficient Upward Rotation

• Structural Variations (alter stresses on the tissues)• thoracic kyphosis




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Insufficient Scapular Upward Rotation

• Impairments in Muscle Activation, Strength, Stiffness, and Length• Shortness, stiffness or dominance

• downward rotators – primarily rhomboids

• Lengthened/insufficient activity of upward rotators - primarily serratus anterior

Kendall


Kendall: Muscles Testing & Function


Kendall: Muscles Testing & Function

MMT of Serratus Anterior

Figure A – During shoulder flexion, scapula does not move into full UR and abduction but SA tests strong.

Figure B – Florence Kendall passively moves scapula so that it is in almost full UR and abduction.

Figure C – When the subject attempts to actively hold the position, the scapula drops back into less scapular UR and abduction.

Why?



•Rhomboids more prominent on left•SH muscles short on right

•Rhomboids more prominent thanother scapular muscles = red flag



•Rhomboids more prominent on left•SH muscles short on right

•Rhomboids more prominent thanother scapular muscles = red flag



• Confirming Test:• Manual correction of

scapular impairments decreases symptoms

• Assess passive resistance to motion




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Scapular Internal Rotation with Insufficient Upward RotationPrimary emphasis of

Intervention:• Improving the performance

of the serratus anterior balanced with the trapezius to improve upward rotation while avoiding excessive scapular internal rotation


Scapular Internal Rotation with Insufficient Upward RotationPrimary emphasis of

Intervention:• Improving the performance

of the serratus anterior balanced with the trapezius to improve upward rotation while avoiding excessive scapular internal rotation



Intervention: Quadruped Rocking Backward

Start with the scapula externally rotated and flat on thorax. Be sure scapula upwardly rotates during rocking backward.



• Starting position - shoulder abduction with lateral rotation to work middle trapezius at shortened length/increase stiffness; stretch pectoralis major

• Horizontal adduction keeping the scapula still, then shoulder flexion allowing the scapula to upwardly rotate


InterventionEvidence for prescribing exercises to improve the performance of the

trapezius and serratus anterior based on EMG data:

• Glousmann R et al 1988• Ludewig PM et al 2000 and 2004• Moseley JB 1992• Scovazzo ML et al 1991


Intervention:• Push up plus was recommended for serratus

anterior strengthening based on maximum EMG activity of muscle Moseley BJ, 1992

• Caution: Maximum EMG activity or a strong muscle does not necessarily result in a better movement pattern.




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Wall Push-up Plus Exercise• From starting position to push-up plus

position there was a significant:• scapular downward rotation• scapular internal rotation

• This may decrease the subacromial space predisposing the person to impingement.

Lunden JB, Braman JP, LaPrade RF, LudewigPM; 2010


Intervention:• Exercises should focus on achieving the correct movement pattern so that muscle is working at its appropriate length• for example select an exercise

with decreased load during shoulder flexion so the scapula moves into full upward rotation

Hardwick D, 2006• Cues to lift fingers “reach for

ceiling” and push slightly into wall.


Scapular Internal Rotation with Insufficient Scapular Upward Rotation

Intervention: Function• “bring scapula around and lift acromion”

whenever reaching overhead. Avoid excessive internal rotation of scapula.

• Don’t allow the acromion to drop during UE activities such as using the mouse



Address Contributing Factors

• stretch SH mm. and posterior capsule

supine horizontal adduction McClure P 2007

• Can also be done with shoulder in LR




Intervention: support arms when sitting to lift acromion


SCAPULAR INTERNAL ROTATION WITH ABDUCTION




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Scapular Internal Rotation with Abduction• Internal Rotation

• With anterior tilt• With insufficient upward rotation• With abduction

• Depression• With insufficient UR (SC & AC joint)

• External Rotation/adduction • With insufficient UR (SC & AC joint)



Scapular Internal Rotation with Abduction

Symptoms• Pain in thoracic region between spine

and scapula- adductor strain vs thoracic rotation

Activities• Swimmers, hairdressers • Cellist• Weightlifters


Scapular Internal Rotation with Abduction - Movement Impairments

During shoulder flexion• Scapula rests in abduction and remains abducted• Greater than ½” of abduction of scapula in first 90

degrees

At end range shoulder flexion• Root of spine of scapula ≥ 3.5 inches (9 cm) from

vertebral spine• Decreased clavicular retraction - < 16°Ludewig PM 2009

During shoulder lateral rotation in prone• Scapula abducts/IR



Excessive scapular abductionand internal rotation during

shoulder flexion

Corrected



Is her diagnosis really scapular internal rotation withinsufficient UR and abduction???



• Alignment:Backview: • vertebral border >3”

(7.5 cm) from spine

Normal scapular alignment

• 3” Sobush DB. 1996 • 2.5” Neumann DA,

2002• 2” (5 cm) Kendall FP,

1993, Hoppenfeld S, 1976

Left scapula 4” (10 cm), right 3.5” (9 cm) from spine




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Activity contributing to abduction: wrestling



Thoracic pain:Segment of thoracic spine is more flexible than shoulder girdle: (Contributing factors: heavy arms, stiff pectoral muscles, scapular abduction)



• right scapular pain and popping

• PhD student working a lot at bench under hood so has to reach forward

• pain at end of day• right handed• large breasts



corrected


Scapular Internal Rotation with Abduction –Right shoulder


Scapular Internal Rotation with Abduction• Structural Considerations:

• thoracic kyphosis or wide thorax• scoliosis• large breasts• large abdomen• obesity • hx of clavicular fracture (healed with overlap)

• Matsumura N et al 2010




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Scapular Internal Rotation with AbductionImpairments • Short or stiff

• Scapular abductors - pectoralis minor, major, serratus anterior

• SH muscles and posterior GHJ capsule

• Lengthened or weak scapular adductors• Activation

• Excessive – scapular abductors and SH muscles• Insufficient - scapular adductors

• trapezius, rhomboids


Scapular Internal Rotation with AbductionPrimary Focus of intervention:• Avoid habitual postures and arm motions of

excessive scapular abduction/IR • Improve performance and stiffness of middle

trapezius is key.• Standing exercises at wall• Prone middle trapezius exercises

• Increase extensibility of SH muscles and GHJ posterior capsule



• Avoid excessive scapular abduction at rest & during arm motions



Faulty

Corrected:• Arms supported • Sit close to desk• Scapula adducted



• Starting position - shoulder abduction with lateral rotation to work middle trapezius at shortened length/increase stiffness; stretch pectoralis major

• Horizontal adduction keeping the scapula still, then shoulder flexion allowing the scapula to upwardly rotate


Scapular Internal Rotation with Abduction• There is some

evidence that sidelying shoulder flexion is a good exercise for the middle trapeziusminimizing upper trapezius activity.• Based on surface

EMG activityCools AM et al 2007




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Intervention Exercises:• prone middle trapezius

progression

1

2 3


Faulty Muscle Activation During Prone Trap Exercise-Lots of Thoracic Extension Instead of Scapular Adduction



Stretch SH muscles and posterior capsule• supine horizontal

adduction McClure P 2007



Scapular IR with AT and ABD


Scapular IR with AT and ABD

video


Dissociating GH from ST Motion

video




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Scapular Syndromes• Internal Rotation

• With abduction• With anterior tilt• With insufficient upward rotation

• Depression• With insufficient upward rotation

• External Rotation/adduction • With insufficient upward rotation



SCAPULAR DEPRESSION WITH INSUFFICIENT UPWARD ROTATION


Scapular Depression With Insufficient Upward Rotation

Symptoms:• Pain can be located in upper trapezius

region• Headaches associated with neck pain

Activities• Dancers esp. ballet• Gymnasts


Scapular DepressionWith Insufficient Upward Rotation

Criteria For Normal Motion During Arm Elevation

• Acromion should be aligned level with C6 -7 at end range

• Clavicle elevates 6-10°when the arm is elevated 120° Ludewig PM 2009



Movement Impairment -Insufficient elevation

• Acromion depresses in the first 90 degrees of shoulder flexion or abduction

• Acromion does not begin to elevate after about 30 degrees of arm elevation

• Acromion below C6 -7 at end range



Movement Impairment

• Scapula depresses when a load is placed on the arm or during prone tests

• Often occurs with insufficient scapular upward rotation




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Scapular Depression with Insufficient Scapular Upward Rotation

Alignment• increased slope of shoulders• vertebral border of scapula

not parallel to spine• humerus in abduction

relative to scapula


Scapular Depression with Insufficient Scapular Upward Rotation

Alignment• Scapula may not be depressed at rest


Depression with Insufficient Scapular Upward Rotation

Unsuccessful Correction of Alignment Using Rhomboids


Depression with Insufficient Scapular Upward Rotation

Unsuccessful Correction of Alignment – corrects scapular downwardrotaton but adduction is excessive


Scapular DepressionAlignment • Increased slope of

shoulders R > L• Scapula lower than

T2 - T7 Swift TR, 1984

• Scapula normally positioned between T2-T7

Kendall FP 1993 and Hoppenfeld S 1976



Alignment• Horizontal clavicles Swift

TR, 1984• normally clavicle should have

slight upward slope • 25-29° Todd TW,1912• 20° Telford S, 1948• 6° Ludewig PM 2009

• Right arm appears longer• Increased slope




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Preferred Corrected



scapdrleft


Neck Pain with Scapular Depression and Cervical Flexion

Pilates Instructor

videos



Secondary Test• Manual elevation of the scapula decreases the symptoms at

rest, on multiple tests throughout the examination

Exam includes correction during functional activities.



Structural Considerations• long arms• heavy arms• large breasts• long neck



Impairments • Lengthened or

weak• Upper trapezius• Serratus Anterior

• Activation• Excessive – latissimus

dorsi and lower trapezius• Insufficient – upper

trapezius




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Primary Focus of Intervention:• Patient education regarding the movement

impairment and how to modify it during daily activities

• Arm support!

• Correcting stiffness, length, activation, and strength impairments of the upper and middle trapezius



Exercises• Active elevation of the scapula especially during the

last 1/2 of the ROM of arm elevation • standing facing wall shoulder flexion

• progress to arm lift• Stretch pectoralis major and minor• Prone middle trapezius

Decrease activation of latissimus during all exercises


Scapular Depression with Insufficient Upward Rotation -

ExercisesStanding shoulder flexion facing wall

with shrugging

Faulty CorrectedAlignment



Function• Support arms when sleeping, sitting and

standing - KEY• Correct height of desk and arm rests on chair• Driving positionOther Treatments• Bra with straps that do not increase pressure

on acromial area• Scapular taping



Arm support while sleeping

Unload shoulder



Arm rests need to be close to body and high enough to support shoulders at correct height. Positioning keyboard on desktop may be better than keyboard tray for arm support.




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Correct alignment while driving.



Decrease load on acromion withproper bra.



Scapular taping


SCAPULAR EXTERNAL ROTATION/ADDUCTION





• External Rotation/adduction• With insufficient upward rotation



Criteria For Normal Motion At End Range Arm Elevation• Root of spine of scapula 3 inches (7.5 cm)

from vertebral spine

• Scapula should be about 10-20°anterior to the frontal plane Ludewig PM 2009

• The vertebral border should be 55-60°relative to the vertical.

External Rotation/AdductionWith Insufficient Upward Rotation




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External Rotation/AdductionWith Insufficient Upward RotationMovement ImpairmentInsufficient scapular internal rotation and abduction usually occurs with insufficient scapular upward rotation

• At the end range of arm elevation :• Root of spine of scapula <2.5 inches from

vertebral spine• Scapula < 10-20°anterior to the frontal plane• Vertebral border < 55°relative to the vertical.



Movement Impairment

Scap-044



Key contributing factor • Excessive activation of the trapezius and

rhomboids prevents normal scapular movement during arm elevation



Impairments in Stiffness and Length

• Rhomboids and middle trapezius are too stiff and/or short

• Serratus anterior is too long


External Rotation/AdductionWith Insufficient Upward RotationImpairments of Resting Alignment• Vertebral border of scapula is < 6.25 cm (2.5”)

from vertebral spine

• Scapula is oriented less than 30°anterior to frontal plane

• Clavicle is retracted more than 20-25°

• The thoracic spinal curve is often decreased or flattened.






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• Scapula less visible from sideviewcompared to person with scapular IR

• Associated with flat thoracic spine.



Primary Focus of Intervention• Cue to relax thoracic spine and stop

constantly contracting scapular adductors.

• Improve performance of the serratus anterior

• Increase extensibility of the rhomboids and middle trapezius.


SCAPULAR WINGINGSCAPULAR ELEVATION





• External Rotation/adduction • With insufficient upward rotation



Scapular WingingMovement Impairment• Scapular winging during flexion and

during the return from flexion

• May have associated scapular depression

• History of long thoracic nerve injury more often than spinal accessory nerve injury.


Scapular WingingStrength of serratus anterior on MMT is < 3/5

Scapular winging -long thoracic nerve injury




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Scapular WingingImpairments in Resting Alignment• Entire vertebral border of scapula

prominent

• Increased scapular internal rotation -greater than 40° anterior to frontal plane


Left Side Involved

Onset after biking trip for several weeks with backpack on back; 20 y/o

Program in Physical Therapy Program in Physical Therapy


Video: initial (left) and 6 weeks later (right)


Exercise at 6 weeks later

video




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Caution

Flat thoracic spine may result in prominence of entire vertebral border but the patient may not demonstrate the movement impairment of scapular winging.

Kendall


Caution

Flat thoracic spine may result in prominence of entire vertebral border but the patient may not demonstrate the movement impairment of scapular winging.


Scapular Winging• Prolonged or habitual scapular

depression may contribute to initial or ongoing nerve irritation.


Scapular Winging

Structural Considerations• Heavy arms


Scapular Winging

Impairment • Strength < 3/5

•Serratus anterior – long thoracic nerve

•Trapezius – spinal accessory nerve


Scapular Winging – SA WeakPrimary Focus of Intervention Compensatory - strength ≤ 2/5 whether or not return of function is expected

• Support the arm in sitting and standing to alleviate the strain on scapulo-cervical structures

• Teach patient precautions• Avoid repetitive overhead activities, heavy

lifting• Improve the performance of the trapezius

muscle, esp upper trap• shrug the shoulder during arm elevation

• Monitor for return of muscle strength




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Scapular Winging –Weak Trapezius

Primary Focus of Intervention Compensatory - strength ≤ 2/5 whether or not return of function is expected

• Support the arm in sitting and standing to alleviate the strain on scapulo-cervical structures

• Teach patient precautions• Avoid repetitive overhead activities, heavy lifting

• Improve the performance serratus and rhomboids• SA – cue to increase scapular upward rotation during

sidelying shoulder flexion • Rhomboids – support scapula in resting alignment

• Monitor for return of muscle strength


Scapular Winging –Weak Serratus Anterior or TrapeziusComponent - if muscle strength is returning• Focus on appropriate activation of the

muscle both concentrically and eccentrically• Initially starting in gravity lessened

position• Particular attention should be paid to

the quality of scapular motion during arm movements





• External Rotation/adduction• With insufficient upward rotation



Scapular ElevationMovement Impairment

• Excessive scapular elevation is usually identified early in the range and continues throughout arm elevation.

• The primary problem is typically limited glenohumeral motion and not poor muscle performance.


Scapular ElevationPrimary Focus of Intervention:

• If GH hypomobility is present - increase GH mobility.

• If rotator cuff function is deficient but expected to return focus is on restoring precise GH without scapular elevation.

• If rotator cuff function is deficient and not expected to improve then scapular elevation as a compensatory technique may be necessary.



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