Download Role of Scapulothoracic Muscles To Provide Stabilization

Management of the Scapula in
Glenohumeral Instability
Steven A Stratton, PT, PhD, ATC
Steven A. Stratton, PhD, PT, ATC
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General Physical Therapy
Orthopaedic Physical Therapy
Manual Therapy
Spinal Rehabilitation
Sports Physical Therapy
Shoulder Complex
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Sternoclavicular Joint
Acromioclavicular Joint
Glenohumeral Joint
Scapulothoracic Joint
Shoulder Complex
Sternoclavicular Joint
Acromioclavicular Joint
Anterior
Superior
Glenohumeral Joint
Shoulder Capsular-Ligamentous Complex
Scapulothoracic Joint
Scapulothoracic Joint
(Protraction)
(Retraction)
Scapular Rest Position
Stability of the Shoulder
Complex
• Stability is maintained by the
glenohumeral ligament complex, the
compressive forces of the rotator cuff,
the glenoid labrum, negative intraarticular pressure, and normal
kinematics of the scapula as part of
scapulohumeral rhythm.
Scapulohumeral Rhythm
• Scapulohumeral rhythm is the
coordinated interaction of the scapula
with a moving humerus to keep the
angle of the humerus and glenoid of
the scapula within a physiological
tolerable range.
• Likened to a “ball on a seal’s nose”.
Rowe CR, Zarins B. Recurrent transient subluxation of the
shoulder. J Bone Joint Surg Am 63: 863-872, 1981.
Scapulohumeral Rhythm
• The coupled motion of the arm and
scapula provides dynamic stability for
the shoulder complex in various
positions of everyday activities and
athletic movements.
Glenohumeral and
Scapulothoracic Contribution
• Shoulder Elevation: 3 degrees of
Glenohumeral (GH) joint motion for every 2
degrees of Scapulothoracic (ST) joint motion.
• McQuade found up to 4.5:1 ratio under heavy
shoulder loading in scapular plane of arm
elevation.
McQuade KJ, Smidt GL. Dynamic scapulohumeral rhythm: the effects of
external resistance during elevation of the arm in the scapular plane.
JOSPT 27(2): 125-133, 1988.
• GH joint with ST contribution seeking a
position of stability relative to humerus.
Patterns of Scapular Dyskinesis
• Type I = abnormal motion
around a horizontal axis
so that the scapula has
abnormal anterior tilt; the
clinical manifestation is
prominence of the
inferior medial scapular
border on arm motion.
Kibler WB. Management of the
scapula in glenohumeral instability.
Techniques in Shoulder & Elbow
Surgery 4(3): 89-98, September 2003.
Patterns of Scapular Dyskinesis
• Type II = abnormal
motion around a
vertical axis so that
the scapula has
abnormal lateral or
external rotation; the
clinical manifestation
is prominence of the
entire medial scapular
border.
Patterns of Scapular Dyskinesis
• Type III = abnormal
motion around a
sagittal axis so that the
medial scapula
translates superiorly
and the lateral scapula
translates inferiorly; the
clinical manifestation is
prominence of the
superior medial border.
Hypermobility
• With Ehlers-Danlos syndrome (EDS),
there is tissue laxity and more fragile
ligaments and tendons; therefore, the
EDS patient is predisposed to joint
laxity causing hypermobility, which
increases the vulnerability of the joint
to injury.
Joint Hypermobility
• Since joint laxity may predispose the
person to experience joint instability,
then improving joint stability must come
from the muscular system.
Joint Stability
• Joint stability by “muscle stiffness” via
gamma-muscle spindle system has been
found to be one of the important variables
in joint stabilization.
• Muscle stiffness has been described as
the “spring-like” quality of muscle.
• When muscle has high stiffness,
increased force is required to cause
lengthening of the muscle.
Johansson H, Sjolander P. Receptors in the knee joint ligaments
and their role in biomechanics of the joint. CRC Critical Reviews in
Biomedical Engineering 18: 341-368, 1991.
Joint Stability
• In the shoulder, a link has been
established between neural structures
and mechanoreceptors in the capsule
and ligaments of the glenohumeral
joint.
Vangsness CT, Ennis M, Taylor JG. Neural anatomy of the
glenohumeral ligaments, labrum, and subacromial bursa.
Arthroscopy 11: 180-184, 1995.
Joint Stability
• In the spine, Panjabi found the smaller deeper
spinal muscles which attach to the lumbar
vertebrae provide ‘segmental stability and
control’ rather than ‘movement’.
Panjabi MM. The stabilizing system of the spine. Part I. Function,
dysfunction, and adaptation and enhancement. J Spinal Disorders
5: 383-389, 1992.
Panjabi MM. The stabilizing system of the spine. Part II. Neutral
zone and instability hypothesis. J Spinal Disorders 5: 390-397,
1992.
Joint Stability
• Lephart showed proprioception of the
symptomatic shoulder was disrupted in
patients with glenohumeral instability
and improved after shoulder
reconstruction.
Muscle Force Couples
• Dynamic equilibrium of the
glenohumeral joint is attained through
efficient function of several force
couples acting to stabilize the humeral
head during arm movement.
• Force couples are muscles that are
paired to control the movement or
position of a joint or body part.
Shoulder Force Couples
• The rotator cuff muscles help to pull the
humeral head into the glenoid of the
scapula while the deltoid muscle allows
movement of the glenohumeral joint
without compressing the rotator cuff
muscles in the suprahumeral space.
• The subscapularis working with the teres
minor add an additional force couple.
DELTOID
INFRASPINATUS
SUPRASPINATUS
DELTOID
Scapular Force Couples
• Scapular Protraction (Abduction)
– Upper trapezius and upper digitations of the
serratus anterior.
• Scapular Retraction (Adduction)
– Upper and lower trapezius, rhomboids and lower
digitations of the serratus anterior.
Inman JT, Saunders M, Abbott L. Observations on the function of the shoulder
joint. J Bone Joint Surg Am 26: 1-30, 1944.
Happee R, Van der Helm. The control of shoulder muscles during goal directed
movements: An inverse dynamic analysis. J Biomech 28: 1179-1191, 1995.
TRAPEZIUS
SERRATUS
ANTERIOR
Scapular Force Couples
• Elevation
– Upper trapezius, levator scapula and upper
digitations of the serratus anterior.
• Depression
– Lower trapezius and lower digitations of
the serratus anterior.
LOWER
TRAPEZIUS
LOWER
SERRATUS
ANTERIOR
Neuromuscular Control
• Neuromuscular control exercises are
performed in protected positions of the
joints.
• Usually begin with closed kinetic chain
exercises since they enhance
compression of the joint and facilitate
co-contraction of the agonistantagonist musculature, increasing joint
stability.
• Then progress to open kinetic chain
exercises.
Exercises
• If patient very weak, then start with
shoulder isometrics (no motion) in
neutral position for shoulder flexion,
extension, internal rotation, external
rotation, abduction; also scapular
adduction with chin tuck seated.
• All exercises have to be performed pain
free.
• Start with 5 second hold for 5 repetitions.
Exercises
• Patient has to be educated in proper
joint positions, proper technique, avoid
heavy lifting, no excessive repetitive
movements, and controlling pain while
exercising.
• Peripheral joints may have to be
protected to exercise the shoulders or
shoulder girdle.
Exercises
EDS patient may
need wrist support
to perform
TheraBand shoulder
exercises.
Exercises
Elbow joint may also
need to be
protected.
Exercises
• Closed Kinetic Chain
– Closed Chain Scapular Motion
– Scapular Clocks
– Low Row
– TheraBand Neutral Shoulder
– TheraBand Scapular Adduction
– TheraBand Scapular Adduction with Shldr
ER
– TheraBand Prone on Elbows Shldr ER
Exercises
• Closed Kinetic Chain
– Closed Chain
Scapular Motion
– Scapular Clocks
– Low Row
– TheraBand Neutral
Shoulder
– TheraBand Scapular
Adduction
– TheraBand Scapular
Adduction with Shldr
ER
– TheraBand Prone on
Elbows Shldr ER
Exercises
• Closed Kinetic Chain
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Closed Chain Scapular
Scapular Clocks
Low Row
TheraBand Neutral
Shoulder
– TheraBand Scapular
Adduction
– TheraBand Scapular
Adduction with Shldr
ER
– TheraBand Prone on
Elbows Shldr ER
Exercises
• Closed Kinetic Chain
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Closed Chain Scapular
Scapular Clocks
Low Row (retraction/ext)
TheraBand Neutral
Shoulder
– TheraBand Scapular
Adduction
– TheraBand Scapular
Adduction with Shldr
ER
– TheraBand Prone on
Elbows Shldr ER
Exercises
• Closed Kinetic Chain
– Closed Chain
Scapular
– Scapular Clocks
– Low Row
– TheraBand Neutral
Shoulder
– TheraBand Scapular
Adduction
– TheraBand scapular
Adduction with Shldr
ER
– TheraBand Prone on
Elbows Shldr ER
Exercises
• Closed Kinetic Chain
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–
–
–
Closed Chain Scapular
Scapular Clocks
Low Row
TheraBand Neutral
Shoulder
– TheraBand Scapular
Adduction
– TheraBand Scapular
Adduction with Shldr
ER
– TheraBand Prone on
Elbows Shldr ER
Exercises
• Closed Kinetic Chain
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–
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–
Closed Chain Scapular
Scapular Clocks
Low Row
TheraBand Neutral
Shoulder
– TheraBand Scapular
Adduction
– TheraBand Scapular
Adduction with Shldr
ER
– TheraBand Prone on
Elbows Shldr ER
Exercises
• Closed Kinetic Chain
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–
–
–
Closed Chain Scapular
Scapular Clocks
Low Row
TheraBand Neutral
Shoulder
– TheraBand Scapular
Adduction
– TheraBand Scapular
Adduction with Shldr ER
– TheraBand Prone on
Elbows Shldr ER
Exercises
• Closed Kinetic
Chain
– Serratus Anterior
with TheraBand
– Subscapularis with
TheraBand
Exercises
• Open Kinetic Chain Exercises
– Side lying Shldr ER
– Standing Shoulder Abduction Open Can
with DB
– Standing Shoulder Flexion with DB
– Prone Scapular Adduction with
Depression
• Arms at Side
• Flexed Elbows, Thumbs Up (Prone Bird)
– Prone Lower Trapezius (Super Man)
– Supine Serratus Anterior with DB
Exercises
• Open Kinetic Chain
Exercises
– Side lying Shldr ER
– Standing Shoulder
Abduction Open Can with DB
– Standing Shoulder Flexion
with DB
– Prone Scapular Adduction
with Depression
• Arms at Side
• Flexed Elbows, Thumbs Up
(Prone Bird)
– Prone Lower Trapezius
(Super Man)
– Supine Serratus Anterior
with DB
Exercises
• Open Kinetic Chain
Exercises
– Side lying Shldr ER
– Standing Shoulder
Abduction Open Can with DB
– Standing Shoulder Flexion
with DB
– Prone Scapular Adduction
with Depression
• Arms at Side
• Flexed Elbows, Thumbs Up
(Prone Bird)
– Prone Lower Trapezius
(Super Man)
– Supine Serratus Anterior
with DB
Exercises
• Open Kinetic Chain Exercises
– Side lying Shldr ER
– Standing Shoulder Abduction
Open Can with DB
– Standing Shoulder Flexion
with DB
– Prone Scapular Adduction
with Depression
• Arms at Side
• Flexed Elbows, Thumbs Up
(Prone Bird)
– Prone Lower Trapezius
(Super Man)
– Supine Serratus Anterior with
DB
Exercises
• Open Kinetic Chain Exercises
– Side lying Shldr ER
– Standing Shoulder Abduction
Open Can with DB
– Standing Shoulder Flexion
with DB
– Prone Scapular Adduction
with Depression
• Arms at Side
• Flexed Elbows, Thumbs Up
(Prone Bird)
– Prone Lower Trapezius
(Super Man)
– Supine Serratus Anterior with
DB
Exercises
• Open Kinetic Chain
Exercises
– Side lying Shldr ER
– Standing Shoulder
Abduction Open Can with
DB
– Standing Shoulder Flexion
with DB
– Prone Scapular Adduction
with Depression
• Arms at Side
• Flexed Elbows, Thumbs Up
(Prone Bird)
– Prone Lower Trapezius
(Super Man)
– Supine Serratus Anterior
with DB
Exercises
• Open Kinetic Chain
Exercises
– Side lying Shldr ER
– Standing Shoulder
Abduction Open Can with
DB
– Standing Shoulder Flexion
with DB
– Prone Scapular Adduction
with Depression
• Arms at Side
• Flexed Elbows, Thumbs Up
(Prone Bird)
– Prone Lower Trapezius
(Super Man)
– Supine Serratus Anterior
with DB
Exercises
• Open Kinetic Chain Exercises
– Side lying Shldr ER
– Standing Shoulder Abduction
Open Can with DB
– Standing Shoulder Flexion
with DB
– Prone Scapular Adduction
with Depression
• Arms at Side
• Flexed Elbows, Thumbs Up
(Prone Bird)
– Prone Lower Trapezius
(Super Man)
– Supine Serratus Anterior with
DB
Remember that all exercises have to be
performed pain free, with a slower
progression, and the patient must
maintain all joints in a protected and
properly aligned biomechanical position.
170 °
170°
Joint Capsule/
Coracohumeral
Ligament
G
Scapulohumeral Rhythm
SC Jt.- 30° elevation
Scapula = 60°
180°
15° early (35°)
AC Jt.
Glenohumeral = 120°
15° late (135°)
Closed Kinematic Chain
Dvir,1978
References
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Scapula and Glenohumeral Joint
1.
Barton LM, Bird HA. Improving pain by the stabilization of hyperlax joints. J Ortho Rheum 9: 46-51, 1996.
2.
Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder; spectrum of pathology part III: the
SICK scapula, scapular dyskinesis, the kinetic chain, and rehabilitation. Arthroscopy 19(6): 641-661, 2003.
3.
Cools AM, Witrouw ES, Declercq GA, Vanderstraeten GG, Cambier DC. Evaluation of isokinetic force
production and associated muscle activity in the scapular rotators during a protraction-retraction movement in
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Ekstrom RA, Bifulco KM, Lopau CJ, Anderson CF, Gough JR. Comparing the function of the upper and
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6. Hall MG, Ferrell WR, Sturrock RD, et al. The effects of the hypermobility syndrome on knee joint
proprioception. Brit J Rheum 34: 121-125, 1995.
7.
Happee R, Van der Helm. The control of shoulder muscles during goal directed movements: An inverse
dynamic analysis. J Biomech 28: 1179-1191, 1995.
8.
Inman JT, Sanders M, Abbott L. Observations on the function of the shoulder joint. J Bone Joint Surg Am
26: 1-30, 1994.
9.
Johansson H, Sjolander P. A sensory role for the cruciate ligaments. Clin Ortho & Related Res 268: 161178, 1991.
10. Johansson H, Sjolander P. Receptors in the knee joint ligaments and their role in biomechanics of the joint.
CRC Critical Reviews in Biomed Engineering 18: 341-368, 1991.
11. Kibler WB. Shoulder rehabilitation: principles and practice. Med Sci Sports Exer 30(4): 40-50, 1998.
12. Kibler WB. The role of the scapula in athletic shoulder function. Am J Sports Med 26: 325-337, 1998.
13. Kibler WB. Management of the scapula in glenohumeral instability. Techniques in Shoulder & Elbow Surgery
4(3): 89-98, 2003.
14. Kibler WB, Tambay NS. Shoulder inquiry encompasses kinetic chain structures. Biomechanics, 49-57, 2005.
References, cont.
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proximal interphalangeal joint in patients with hypermobility syndrome. Brit J Rheum 33: 386-398,
1994.
17. McQuade KJ, Smidt GL. Dynamic scapulohumeral rhythm: the effects of external resistance
during elevation of the arm in the scapular plane. JOSPT 27(2): 125-133, 1988.
18. Panjabi MM. The stabilizing system of the spine. Part I. Function, dysfunction adaptation and
enhancement. J Spinal Disorders 5: 383-389, 1992.
19. Panjabi MM. The stabilizing system of the spine. Part II. Neutral zone and instability
hypothesis. J Spinal Disorders 5: 390-397, 1992.
20. Rowe CR, Zarins B. Recurrent transient subluxation of the shoulder. J Bone Joint Surg Am
63: 863-872, 1981.
21. Rubin BD, Kibler WB. Fundamental principles of shoulder rehabilitation: conservative to post
operative management. Arthroscopy 18(9): 29-39, Nov 2002.
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