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Sydney Physiotherapy Solutions
Matt Crawshaw
Blair Chapman
Chantal Wingfield
Today’s Topic is The Scapular
 Shoulder pathology
 Measuring static and dynamic scapular stabilisation
 Using measurements to screen for prevention of
shoulder injuries and to identify scapular dysfunction
due to injury.
 Using measurements to progress rehabilitation.
Today’s Goal
1. Interact and Share
 discuss shoulder injuries from the Personal Trainers perspective
 discuss shoulder injuries from the physiotherapist perspective
 suggest a framework where the Personal Trainers and the
Physiotherapists can be a team for the client with a focus on
keeping them training with the Personal Trainer through their
2. Develop trust with you
Framework for Physio’s and PT’s
to work within
When we receive a patient from a PT with a
Shoulder problem
 Our responsibility lies equally between the patient and the
 We need to establish a diagnosis and prognosis and
communicate that to the patient and the PT.
Framework for Physio’s and PT’s
to work within
 To reduce Symptoms and address the likely poor
scapular stabilising strategy that is present as a reaction
to the injury.
 To give patient back to PT with minimal Sx and a good
scap stabilising strategy for the PT to load that strategy
to regain full strength .
Framework for Physio’s and PT’s
to work within
 Important for the PT to understand how to identify good
and bad scap stabilising strategies and to be able to
monitor this during strength training.
 We need to do this as soon as possible to maintain the
relationship between patient and PT. If there is a longer
period of rest required for the shoulder we need to
provide the PT with safe strengthening exercises to do
during the rehab process.
More detail of this Framework
 Chantal is going to present the pathologies we are
thinking of when a shoulder injury is referred to us from
a PT and how we diagnose this.
 Blair will describe the current understanding of scap
stabilisation and how it is affected by injury. He will
run a small practical session on how to measure and
identify this for screening your clients before strength
training and rehabilitating your clients back into
strength training post injury.
Shoulder Pathologies
 Fracture
Alternative considerations
 Dislocation
 Cervical spine
 Muscle tear
 Thoracic ring dysfunction
 Labral tear
 Thoracic outlet syndrom /
Brachial plexus
 ACJ injuries
 Frozen shoulder
 Arthritis
 Subacromial impingement –
including tendinitis, bursitis
and postural dysfunctions
 Peripheral neuropathies
 Tumors / lung Ca / heart
 Usually traumatic
 Anterior most common
 Be aware of the chronically
unstable shoulder
 Physiotherapy input recommended
and usually imagery required as
recurrence is highly likely
 Surgical stabilisations occasionally
required in presence of structural
defect EG Bankart, unstable SLAP
or Hill Sachs
Muscle tear
 E.g. Rotator cuff but not
 Can be traumatic or
• Usually causes pain upper arm
• Often but not always complain of weakness
• Needs physio input +/- orthopaedic input depending on
extent of tear/dysfunction & duration of symptoms
• Diagnosed clinically with use of US or MRI as required
• If traumatic, timing is key as better surgical outcomes
within 3 months of injury
Labral Tear
 Can be traumatic or degenerative
 Can be asymptomatic
 Can cause clicking, feelings of instability or deep
shoulder ache
 Physio input recommended with ongoing PT.
 Physio to guide re ex precautions &
rehabilitate shoulder stability whilst training
• Occasionally surgical input required if unstable or fail
conservative input
• Caution with shoulder weight bearing and overhead
loading during initial rehab phase
 Usually managed conservatively
 We will grade the injury and guide regarding their rehab and
ongoing training
 Avoid distraction / loading / weight bearing for ~ 2–6 weeks
depending on grade of injury
 Important to ensure normal mechanics post injury as can lead
to secondary problems such as impingement
Frozen Shoulder
 AKA ‘Adhesive Capsulitis’
 Inflammation and scarring
of your joint capsule
 Starts as a painful
shoulder and develops
into a stiff shoulder
 More common in diabetics
• Needs range maintenance exercises and
occasionally onward referral for a corticosteriod
injection or capsular release
 Osteoarthritis is also known
as joint ‘wear and tear’
 Older population
 Stiffness and pain
• Need careful grading of exercises, not too high
loads as indicative that their cuff and labrum are
severely degenerative
• Very occasionally referred for shoulder replacement
but outcomes currently limited. Good pain responses
but ROM and strength outcomes poor so last resort.
Subacromial Impingement – Bursitis /
 Can occur post trauma, with
overuse, sudden increase in
training or gradual insidious onset
as a result of poor biomechanics
• Present with pain during arm elevation at end of range
or often a painful arc and usually HBB also sore
Additional Potential Differentials
 Cervical spine
 Upper lung lobe
 Cervical arteries
 Heart
 Thoracic outlet / brachial plexus
 Peripheral neuropathy
 Thoracic ring dysfunction
 If unsure, refer to us and we will happily assess and give feedback
 We utilise a series of clinical tests, questions and real time ultrasound
to establish our diagnosis and then will develop a collaborative
management plan with both you and the client
Scapular Mechanics
Scapular Movement
Muscle Actions
Upward Rotation
Serratus anterior, UFT,LFT
Downward Rotation
Levator scapula, Rhomboids,
Pec minor
Anterior/Posterior Tilting
Anterior: Pec minor
Posterior: LFT
Protraction/ Retraction
Protraction: Pec minor, serratus anterior
Retraction: Rhomboids, Trapezius as a whole (latissimus dorsi if humerus fixed)
External Rotation
Serratus anterior
Internal Rotation
Common Presentation
 As a result of injury or trauma
 Downward rotation
 Anterior tilt
 Medial rotation
 Which muscles are overactive?
 Secondary Issues?
Visual Assessment
Kibler Classification of Scapular Dysfunction
Type 1 or inferior Dysfunction
Main feature is inferior angle prominence as a result of anterior tilting.
Best seen with hands on hips or eccentric lowering of arms from overhead ( most
common in rotator cuff dysfunction)
Type 2 or medial Dysfunction
Prominence of entire medial border of scapula due to internal rotation of scapula.
Best seen with hands on hips, eccentric lowering from overhead
Common in shoulder joint instability
Type 3 or Superior Dysfunction
Excessive and early elevation of the scapula during elevation.
Ie. Shoulder Shrugging.
Often seen in rotator cuff dysfunction and deltoid rotator cuff force coupling
Studies support validity of visual observation of scapular dyskinesis
Rotator Cuff Function
 What is the function of the rotator Cuff?
 Relationship with scapula
 Arm abduction
(Lateral raises, military press)
 Horizontal adduction
(chest press, fly’s)
 Shoulder flexion
(front raises, boxing)
Observation Examples
Any questions