Munaf MewafaroshPhysiotherapist

Al-Jahra Hospital

Shoulder ComplexShoulder Complex

Sternoclavicular JointSternoclavicular Joint

Acromioclavicular JointAcromioclavicular Joint

Glenohumeral JointGlenohumeral Joint

Scapulothoracic JointScapulothoracic Joint

Scapulothoracic JointScapulothoracic Joint

Scapulothoracic JointScapulothoracic Joint

(Protraction)(Protraction)(Retraction)(Retraction)

Scapular Rest PositionScapular Rest Position

Scapula Elevation and Depression

Superior trapeziusLevator scapulaeRhomboids

Pectoralis minorInferior trapeziusSerratus anterior Ant part

Scapula Retraction and Protraction

RhomboidsMiddle trapeziusLatissimus dorsi

Pectoralis minorSerratus anterior

Scapula Upward rotation and Downward rotation

Superior trapeziusInferior trapeziusSerratus anterior (Inferior part)

Pectoralis minorLevator ScapulaeRhomboidsLatissimus dorsi

Scapula Stability One of the primary functions of the

scapulae is to provide a stable base from which to create movement in the upper body

The shoulder is a complex joint with

multiple articulations (between the spine, scapulae and humerus) During movement of the arm, a set process known as ‘Scapulo-humeral rhythm' occurs

Scapulo-Humeral Rhythm Scapulo-humeral rhythm serves at

least two purposes

Preservation of the length-tension relationships of the glenohumeral muscles

It prevents impingement between the humerus and the acromion

What is Scapular Dyskinesis? Alteration in the normal static or

dynamic position or motion of the scapula during coupled scapulohumeralmovement

It may be due to alterations in bony stabilisers, muscle activation patterns or lack of strength in the dynamic muscle stabilisers. (Kibler, 1998)

Other names given to this catch-all phrase include: “floating scapula” and “lateral scapular slide”

When describing the static position of the scapula, if an asymmetry is observed, then this should be referred to as ‘altered scapular resting position’ rather than scapular dyskinesis (Kibler & Sciascia, 2010)

Alterations in scapular position and motion occur in 68 – 100% of patients with shoulder injuries

Kibler’s Classification Of Scapular Dyskinesis

Prominence Of Inferior Medial Scapular Border

Abnormal Rotation Around Transverse Axis

Indicates Weakness Of Lower Trap, Lat Dorsi, Serratus anterior Or

Tight Pect Minor,major

TYPE 1

TYPE 2 Classic Winging

Prominence of entire medial Scapular border

Abnormal rotation around vertical axis

Indicates weakness of Serr ant,rhomboids,all fibers of trapezius

TYPE 3 Prominence Of Superior Medial Scapular Border With Superior Translation Of Entire Scapula

Indicates Overactivity Of Levator Scapulae & Imbalance Of Upper & Lower Trap Force Couple

Postural abnormality or anatomical disruption

Nerve Injury

Lack of muscular / capsular flexibility or contracture

Muscle imbalance or weakness

Proprioceptive Dysfunction

Tests for Scapular Dyskinesis Scapular Retraction Test (SRT)

Scapular Assistance Test (SAT)

Lennie Test

Lateral Scapular Slide Test

Wall push- ups

Flip Test

Scapular Retraction Test (SRT)

Scapula can be normally held in retraction with isometric pinch for 15 to20 seconds without burning pain or muscle weakness

Scapular muscle weakness may manifest as inability to maintain a sustained contraction along with burning pain in less than 15 sec (Rhomboids)

Scapular Assistance Test (SAT)During abduction or forward

elevation, assistance is provided by manually stabilizing the scapula and rotating inferior medial border of scapula

This process simulates force couple activity of serratus anterior and lower trapezius

Elimination or modification of impingement symptoms indicate a positive test

Lennie Test Compare scapular

measurements at 3 positions

1. T2 (superior angle)

2. T4 (scapular spine)

3. T7 or T8 (inferior angle)

Lateral Scapular Slide Test Inferior – medial angle of scapula is palpated &

marked on both the sides The reference point on the spine is nearest spinous

process, which is marked Distance is measured on both the sides in three

different positions -A. At resting positionB. With hands on hips, with fingers anterior

&thumb posteriorC. With the arms at 90 degrees with internal

rotation A 1.5 cm asymmetry is the threshold for abnormality

Wall Push – Ups Test Wall push ups are

effective for evaluating serratus anterior strength

Abnormalities may be noted with 5 to 10 Wall push –ups

Flip Test Resisted External

rotation - Scapular medial border Winging indicates a Positive test

Indicates Scapular muscle weakness

Pectoralis Minor Tightness

Supine : Distance from posterior acromion to table

Normal : < 1cm Difference

Effect of Scapula Repositioning TestResearch Report - JOSPT, January 2008,

Volume 38

Study Design : Two-group, repeated measures design

Objectives : To determine whether manually repositioning the scapula using the Scapula Reposition Test (SRT) reduces pain and increases shoulder elevation strength

Methods & Measures : 142 college athletes underwent testing for clinical signs of Shoulder impingement. Tests provoking symptoms were repeated with the scapula manually repositioned in to greater retraction and posterior tilt

A numeric rating scale and a dynamometer were used to measure symptom intensity and Isometric shoulder elevation strength respectively

Results : Of the 98 athletes with a positive impingement test, 46 had reduced pain with scapular repositioning

Repositioning produced an increase in strength in both the impingement (P = 0.001) & nonimpingement groups (P = 0.012) a significant increase in strength was found with repositioning in 26% of athletes with and 29% of athletes without positive signs for shoulder impingement

Conclusion : The SRT is a simple clinical test that may potentially be useful in an impairment based classification approach to shoulder problems

Implication : The SRT may be a way to identify people most suitable for interventions addressing the scapula, such as strengthening, taping or bracing

Limitation : This study only assessed over head athletes who were either asymptomatic or whose symptoms did not cause them to seek medical care, therefore, direct extrapolation of these results to a patient population is not possible

Pain relief modalities

Correct Postural dysfunction

Avoid painful UE movements & Fatigue of the scapulohumeral / thoracic muscles

Soft tissue or Joint Mobilization (if indicated)

PNF patterns for hip and trunk muscles Trunk extension + lateral rotation

facilitates scapular retraction

Trunk flexion + medial rotation facilitates scapular protraction

Regain proximal scapular control & strength before loading the rotator cuff

CKC OKC Exercises

Scapular Clock at 12 & 6

Elevate and depress the scapula with fingers pointed up towards the 12 and 6 o’clock positions

Scapular Clock at 9 o’clock

Retract and protract the scapula with fingers pointed in to 9 o’clock position

Scapular Clock at 3 o’clock

Retract and protract the scapula with fingers pointed in to 3 o’clock position

Low Row Extend the

trunk, pushing the hand forcefully against the edge while simultaneously retracting and depressing the scapula for 5 seconds repeated 10 times

CKC Scapular Motion

Wall Washes

Theraband Neutral Shoulder

Theraband Scapular Adduction

Theraband Scapular Adduction with Shoulder ER

Theraband Prone on Elbows Shoulder ER

Serratus Anterior with Theraband

Subscapularis with Theraband

The Lawnmower

The Robbery

Recovery Phase (3 – 8 weeks)

Begin with isometric active assistive concentric eccentric contractions

Begin kinetic chain tubing exercises PNF D2 pattern

Finger Ladder

Wand / Cane exercises

Blackburn exercises

Serratus anterior punch/press

Side Lying Shoulder ER

Shoulder Abduction/Flexion with DB

Scapular Adduction with Depression

Prone Lower Trapezius (Super Man)

Plank

Maintenance Phase (6 – 10 weeks) Must have good scapular control and motion

throughout range of shoulder motion for this phase

Combine OKC UE exercises with LE and trunk mass movement patterns

Rhythmic stabilization of rotator cuff muscles

Eccentric lowering activities against finger ladder

Plyometrics with medicine ball

Scapular retraction depression with Theraband

Trapezius Exercises

Seated / Chair Push-ups / Dips

Bent – Over Row with DB

Lat Pull down

Plyometrics with Medicine Ball