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Download The Scapular_PT seminar - Sydney Physiotherapy Solutions
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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 injury. 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 PT. 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 Dislocation 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 exclusive Can be traumatic or degenerative • 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 ACJ 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 Arthritis 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 / tendinitis 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 imbalances 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 Summary Any questions ?
