Download Describe methods to evaluate for scapular dyskinesis Perform a

Describe methods to evaluate for scapular dyskinesis
ƒ Perform a scapular dyskinesis examination ƒ
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
z
With humeral elevation, the scapula:
• Externally Rotates (24°), Upwardly Rotates (50°), and Posteriorly Tilts (30°)
• Translates superior and posteriorly, as defined by Translates superior and posteriorly as defined by the position of the scapula via clavicular motion • Clavicular elevation (sup translation) & retraction (posterior trans)
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ƒ Ratio of motion btw the UR: 50°
PT: 30°
ER: 24°
humerus & scapula (UR) during shoulder elevation 30 elevation: ƒ 00°‐30°
minimal scapula mov’t
ƒ 30° & above:
• 2:1 ratio: 2° H: 1° Scap
• Evidence indicates:
20°
90°
120° 140°
Humeral elevation
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• Not exactly linear
• Not symmetrical bilaterally
Thoughts….
ƒ So do these scapular dysfunction lead to the patholgoy?
p
g y
▪ Chicken or the egg?
ƒ Meaningfulness of these differences… are these clinically important???
ƒ Can we identify scapular dyskinesis
clinically?
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“An observable alteration in scapula position & motion pattern relative to the thorax” (Kibler, 2003)
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No standard system for identifying scapular dyskinesia clinically
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Limited evidence as to how a scapular Dx or evaluation guides treatment 2
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7 Test movements (5 reps each)
ƒ Active and weighted flex (F:3lb / M:5lb)
ƒ Active and weighted abduction (F:3lb / M:5lb)
ƒ Wall and plinth push‐ups with a “plus”
ƒ “Flip” test (resisted ER in neutral)
McClure et al 2002
Resisted ER Scapular medial border winging: “+” test
ƒ If the scapular ms are not strong, then they cannot stabilize the scapula as the ER ms contract ƒ
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Potential Abnormalities
ƒ Winging ▪ Posterior displacement of inferior angle or medial border
ƒ Dysrhythmia ▪ Lack of “normal” scapulohumeral rhythm during raising/lowering
ƒ Must be present during 2 of the 5 reps
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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
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Describes a lack of “smooth” scapulohumeral rhythm
ƒ A “hitch or a jump in the otherwise smooth motion.”
(Kibler, 2003)
ƒ Most common pattern is early/excessive scapular elevation (shrug)
ƒ Another common pattern: rapid downward rotation during lowering (dump)
ƒ Posterior view
Picture: Example of “shrug” during arm raising
Picture:“Dumping” during arm lowering
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Symptom Alteration Tests
y p
ƒ Scapular Reposition Test
ƒ Scapular Assist Test
ƒGrasp scapula with fingers contacting coracoid and/or AC joint and apply a posterior & external rotary and mild retraction force q y
with forearm obliquely contacting scapula toward inferior angle as a counterpressure.
ƒRe‐ perform painful mov’ts
or actions such as:
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ƒStabilizes the upper scapular border into mild retraction and assists UR of the inferomedial
bo de t t e t u b
border with the thumb until manual contact is not further possible.
ƒRe‐ perform
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Arm elevation and look to eliminate painful arc
Arm elevation
Neer’s test
Hawkin’s test
Jobe’s test (empty can) 1. Shoulder pathology
2. Poor posture
ƒ Tight Pectoralis
Ti ht P t li
minor: ↓IR
ƒ Supine: distance from posterior acromion to table
ƒ Normal: < 1cm diff
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2. Poor posture
ƒ T‐ & C‐spine: ↑ed flex of T or C‐spine alter scap kinematics (↓UR & PT)
ƒ Postural assessment ▪ Acromion lined up with L‐spine?
▪ T‐spine
Kyphosis?
▪ C‐spine
Forward
head?
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4. Scapular ms
3. Posterior Shoulder Tightness
ƒ Theorized to alter scapular kinematics, particularly in kinematics particularly in overhead throwers (Myers JB, AJSM, 2006)
ƒ Test: ▪ Stabilize scapula by pushing on the on lateral boarder
▪ Horizontally adduction
▪ Normal: ~ 95 degrees of add
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ƒ ↓Serratus Ant & Lower Trap activity: associated with impingement & scapular dyskinesis
d k
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Highest ms activity: Abd or scapular plane elevation and resist shoulder elevation
•Resisting
protraction:
does not
elicit as
much as
SA ms
activity
5. Rotator cuff ms: ER’s
ƒ Fatigue of RC Æ ↓PT, ↓ER, ↑or ↓ UR, ↑clavicular retraction (Tsai N, APMR, 2003; Ebaugh D, 2006)
ƒ Block of suprascapular N. Æ ↑ER & ↑ UR (McCully S, Clin Bio, 2006)
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Highest ms activity for the LT: ƒ
Highest ms activity for the ER and IR: ƒ MT and LT ms tests produced about the same ms activity (not sig. different from each other)
ER test
IR test
Lower Trap muscle test
Middle Trap muscle test
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