The Scapula Counts Too!

1The Scapula Counts Too! Incorporating Scapular Exercises

into Shoulder Rehabilitation

Brady L. Tripp PhD, ATCFlorida International University

Mini-course Goals

We willz Review the role of scapula in shoulder function and dysfunctionz Demonstrate and practice clinical assessment techniques and special

tests to evaluate scapular functionz Identify and discuss components of scapular rehabilitationz Demonstrate and practice methods to integrate scapular stability

exercises into shoulder rehabilitation

This course is designed for clinicians who wish to enhance theirability to assess and rehabilitate shoulder dysfunction. We willdiscuss and practice advanced clinical techniques to assess scapular function and integrate scapula control exercises into shoulder rehabilitation. We will review material using brief PowerPoint presentations followed by demonstrations and hands-on experience applying the assessment and rehabilitation techniques.

Agenda1. Clinical Exam2. Shoulder Foundation Understanding Function of the ScapulaComponents of Scapular Control3. Posture / Postural Awareness 4. Flexibility, Neuromuscular Control, Strength and EnduranceDeveloping Stability5. Continuum of Stability6. Engraining Functional StabilityIntegrating Scapular Control into Rehabilitation7. Progressive VariationTake Home PointsQuestions

Dr. Tripps Tips for Shoulder Rehabilitation

1. Clinical exam is VITAL! 2. Proximal stability is the foundation for distal stability, mobility

and function3. Poor posture / postural awareness and pain inhibit progress4. Stability requires flexibility, neuromuscular control, strength

and endurance5. Stability is a continuum, develop it as a continuum

static dynamic functional 1-joint multi-joint functional

6. Engrain motor patterns that begin with scapular setting7. Use progressive variation to increase demands of exercises;

follow established progression sequence

2Primary Functions of the Scapula

The Scapula a Mobile and Stable Base

Scapula must move consistently with humerus

Clinical Exam and Scapular FunctionGoal: Identify issues, eliminate concerns and develop goals Adequate visualization of landmarks Multiple repetitions of flexion and scaption Adding 1-5 lb weights may help identify deficits Classify scapular motion as NORMALNORMAL

or

ABNORMALABNORMAL

Clinical Exam is VITAL! How would you describe what is going on here?

Scapular Motion

Goal = Identify issuesNORMAL and ABNORMAL Scapular Motion Rotations about 3 axes, in 3 planes

Upward / Downward Rotation Internal / External Rotation Anterior / Posterior Tilt

Superior / Inferior Translation (shrug)

Scapular Upward Rotation

50 5Normal Range

2 5Resting Position

FrontalPlane of Motion

SagittalAxis of Rotation


50 5Normal Range2 5Resting Position


50 5Normal Range2 5Resting Position

3Scapular External Rotation

25 10Normal Range

-30 15Resting Position

TransversePlane of Motion

VerticalAxis of Rotation25 10Normal Range


Scapular External Rotation

Scapular External Rotation

25 10Normal Range


Scapular Posterior Tilt

30 15Normal Range


SagittalPlane of Motion

HorizontalAxis of Rotation


30 15Normal Range-8 5Resting Position


30 15Normal Range-8 5Resting Position

4Clinical Exam Classify scapular motion as normal or abnormal

Abnormal compared to what?Different compared to: 1) ideal = abnormal

2) the other side = asymmetric3) other reps = inconsistent

Ideal scapular motion as the arm elevates :smooth increases in UR, ER and PT

as the arm is loweredsmooth decreases in UR, ER and PT

The humerus is elevating smoothly, the scapula should follow The scapula must maintain a stable alignment with the humerus,

if not we lose dynamic stability

Clinical ExamNormal or Abnormal Scapular Motion?

How do we quantify abnormal?

Clinical Exam

EXAMPLES

Abnormal Upward Rotation

Abnormal Upward Rotation Abnormal Upward Rotation

Lack of adequate UR or poor NMC-inconsistency Shrug initiates movement = superior translation during

elevation

Result: less subacromial space, greater tuberosity closer to coracoacromial arch

5Abnormal Upward Rotation Abnormal Scapular External Rotation

Abnormal Scapular External Rotation

Lack of ER or poor NMC-inconsistency Medial border becomes prominent, lifting off the

thoracic wallResult:

Increased scapulo-humeral angle (transverse plane)

Decreases space between supraspinatus and posterior superior glenoid (i.e. posterior impingement)

Lack of Scapular External Rotation

Abnormal Scapular External Rotation Abnormal Scapular External Rotation

6Abnormal Posterior Tilt Abnormal Posterior Tilt

Lack of adequate PT or poor NMC-inconsistency Inferior angle becomes prominent, lifting off the

thoracic wall posteriorly

Result: Decreases subacromial space, bring greater tuberosity closer to coracoacromial arch (i.e. subacromial impingement)

Abnormal Posterior Tilt Abnormal Posterior Tilt

Abnormal Scapular Motion :Research Findings

Three characteristics were quantified in patients classified as having abnormal kinematics andin pathologic subjects

1. less total IR/ER 2. less consistent IR/ER3. less consistent UR

Impingement Patients( Warner 1992, Lukasiewicz 1999, Ludwig 2000, Hebert 2002 ) Less UR, delayed UR or a more superior

position on thorax (2cm) Less ER Less PT (~9)

May anteriorly tilt as the arm elevates

Abnormal Scapular Motion :Research Findings

7Clinical Exam

PRACTICAL EXAMPLESGoal = Identify1. Normal Scapular Motion2. Abnormal Scapular Motion

Asymmetric? Inconsistent? Lack of: Upward Rotation (shrug)?

External Rot. (medial border prominent)Posterior Tilt (inferior angle prominent)


1. Clinical exam is VITAL! Goal: Identify issues, eliminate concerns and develop goals

2. Proximal stability is the foundation for distal stability, mobility and functionGoal: Build the foundation early (scapular control) before progressing distally


Result:Scapula: less PT (~4 less)

less UR (~5 less)a more superior position

on thoraxGH Joint: less shoulder abduction

(~24less)

Components of Scapular Control

Posture: Forward Head / Kyphosis / Slouching ( Ludwig 1996, Kebaetse 1998 )




3. Poor posture / postural awareness and pain inhibit progressGoal: Address posture and pain first

Muscular Inflexibility

Pectoralis Minor or Biceps (short head)Pulls coracoid anterior/inferiorly Result: Decreased ER and PT,

fwd rounded shoulders

Rehab GoalsAddress Posture!

&Postural Awareness!

What does that mean for this guy?

8Components of Scapular Control

Fatigue Tsai, McClure 2003

PT,ER, UR McQuade, 1998

loss of scapular control McQuade, 1995

PT, UR

What does that mean for these guys?

Rehab GoalsBuild Endurance! Maintain Form!

Serratus Anterior Result: During arm elevation: less UR, less PT,

poor NMC of UR,PT,ERPlus Sign positive= medial border is

not held on thoracic wallScapular Flip Sign positive= medial

border is not held on thoracic wall Pathologic shoulders display decreased Serratus

Anterior activity during arm elevation (Ludwig, 2000)

Muscular Weakness / Neurological

Muscular Weakness / Neurological

Lower and Middle Trapezius Result: During arm elevation: less UR,

lack of PT (tilts anteriorly), lack of ER (internally rotates), poor NMC of UR,PT,ER

Plus Sign positive= medial border is not held on thoracic wall

Scapular Flip Sign positive= medial border is not held on thoracic wall

Overhead athletes with impingement display delayed activation of Lower and Middle Trap during arm elevation (Cools, 2003)

Muscular Dominance / Inflexibility

Upper TrapeziusShrug initiates movement =

superior translation during elevation

Result: During arm elevation: lack of adequate UR, poor NMC of UR

Pathologic shoulders displayed increased EMG during arm elevation with a load (Ludwig, 2000)

Effecting Scapular PositionTo increase upward rotation, external rotation,

posterior tilt:Strengthen:

Serratus AnteriorLower and Middle Traps

Increase Flexibility, Limit Dominance: Upper Trap and LevatorPec Minor

Who will rehab help?

Scapular Retraction TestDuring Active Flexion:Examiner: one hand supporting the

elbow/forearm, the other hand retracting and posteriorly tilting the scapula.

Positive Finding:Improved strengthReduction or elimination of symptoms

9Scapular Assistance TestDuring Active Flexion:Examiner: one hand stabilizing root of

scapular spine, assisting upward rotation; the other assisting posterior tilt at the inferior angle

Positive Finding:Improved strengthReduction or elimination of symptoms





4. Stability requires flexibility, neuromuscular control, strength and endurance

Goal: Develop each component of stability


Developing StabilityStability is a continuum, develop it as a continuum

single multi-joint functionalstatic dynamic functional Examples?

Rhythmic Stabilization Scapular Clock

Create a StableStable Base! Create a MobileMobile Base!

Developing StabilityEngrain motor patterns that begin with scapular setting

Create a Stable Base!





4. Stability requires flexibility, neuromuscular control, strength and endurance

Goal: Develop each component of stability5. Stability is a continuum, develop it as a continuum

static dynamic functional; single multi-joint functionalGoal: Develop stability as a continuum progressing to functional

6. Engrain motor patterns that begin with scapular settingGoal: Emphasize beginning movement with a stable base

10


Integrating Scapular Control into Rehabilitation

Use Progressive VariationProgressive Variation to modify exercises to achieve Goals

Clinical Exam Identifies Goals Build the foundation early (scapular control) before

progressing distally Address posture and pain first Develop each component of stability Develop stability as a continuum progressing to functional Emphasize beginning movement with a stable base

Progressive VariationExercise Variables Clinicians Can Manipulate to AdvanceDemands and Address Goals of Rehabilitation

Integrating Scapular Control into Rehabilitation

EXAMPLES

Examples

Progressive Variation

Examples


11

Examples


Video

ExercisesInferior Glide

Robbery

ExercisesLow Row

Lawnmower

ExercisesScapular Clocks

Rhythmic Stabilization

ExercisesProgression

Downward Rows

ExercisesForward Punch

Push-ups with +

12

Examples

Internal Rotation and Posterior Capsule (GIRD)Sleeper Stretch

Address Posture / Increase Flexibility

Anterior Shoulder Flexibility Muscles attaching to the coracoid

Pectoralis minor Short head of the biceps Coracobrachialis


Take Home Points1. Clinical exam is VITAL! 2. Proximal stability is the foundation for distal stability, mobility

and function3. Poor posture / postural awareness and pain inhibit progress4. Stability requires flexibility, neuromuscular control, strength

and endurance5. Stability is a continuum, develop it as a continuum

static dynamic functional; single multi-joint functional6. Engrain motor patterns that begin with scapular setting7. Use progressive variation to increase demands of exercises;

follow established progression sequence

Thank You

Questions?

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The Scapula Counts Too!

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