scapular dyskinesia: shoulder’s nightmare-a narrative...
TRANSCRIPT
-
Miraj Medical Center Journal of Physiotherapy 2019 VOL 1 NO. 1 3 www.mmcjopt.org
Scapular dyskinesia: Shoulder’s Nightmare-A Narrative
Review on Current concepts
Dr Ajit S Dabholkar (M.P.Th, PhD)1
1Professor and Head of Sports Physiotherapy, School of Physiotherapy,
D.Y.Patil University, Nerul, Navi Mumbai
Address all correspondence and requests for
permission: Dr Ajit S Dabholkar
Email- [email protected]
Phone- +919892502160
Copyright: 2019 Miraj Medical Centre’s Journal of Physiotherapy
Abstract:
Background: The ‘‘Scapula Summit’’
was founded, where experts in this field
meet to discuss the biomechanical and
clinical factors attributed to the scapula
in causing shoulder pathologies, in
particular, ‘‘scapula dyskinesis. In this
review the author explored the
contemporary concepts in the
understanding and management of
scapular dyskinesis.
Objectives: To appraise the literature
and understand the current concepts in
evaluation of scapular dyskinesis,
clinical implications and factors
influencing abnormal kinematic
alterations and relevant strategies for
management.
Methods: Literature review of
scapular dyskinesis and its implications
were selected by an approach called
“best evidence synthesis.” The articles
included were searched in Databases
like PubMed, Cochrane and Google
scholar. Articles included were current
approaches in assessment and
management of scapular dyskinesis,
Systematic Reviews, Metaanalysis,
Current Literature review.
Discussion: There is evidence of
scapular kinematic alterations
associated with shoulder impingement,
http://www.mmcjopt.org/mailto:[email protected]
-
Miraj Medical Center Journal of Physiotherapy 2019 VOL 1 NO. 1 4 www.mmcjopt.org
rotator cuff tendinopathy, rotator cuff
tears, glenohumeral instability,
adhesive capsulitis, and stiff shoulders.
There is also evidence for altered
muscle activation in these patients,
particularly, reduced serratus anterior
and increased upper trapezius
activation. Scapular kinematic
alterations similar to those found in
patient with a short rest length of the
pectoralis minor, tight soft-tissue
structures in the posterior shoulder
region, excessive thoracic kyphosis.
This suggests that attention to these
factors is imperative in the clinical
evaluation of scapular dyskinesis and
appropriate strategy need to be
intervened.
Conclusion: The published clinical
evidence endorses clinical evaluation
of scapular dyskinesia and its
associated impairments. The is a need
to understand the factors influencing
scapular dyskinesia through a thorough
comprehensive movement system
impairment. This will ensure
appropriate physiotherapy intervention
with sound clinical reasoning. This will
impact patient outcome positively and
improve quality of life in long term.
Key words: Scapula, Scapular
dyskinesia, Scapular rehabilitation,
scapular kinematics, scapular
dysfunction
Introduction:
The exact role and the function of the
scapula are misunderstood in many
clinical situations. This lack of
awareness often translates into
incomplete evaluation and diagnosis of
shoulder problems. In addition,
scapular rehabilitation is often ignored.
Recent research, however, has
demonstrated a pivotal role for the
scapula in shoulder function, shoulder
injury, and shoulder rehabilitation.1
Understanding of the shoulder and
surrounding structures has increased it
has become well accepted that the
scapula plays several roles in
facilitating optimal shoulder complex
function when scapulohumeral
anatomy and biomechanics interact to
produce efficient movement.2
In normal upper quarter function, the
scapula provides a stable base from
which glenohumeral mobility
occurs.2 Stability of the scapulothoracic
joint depends on coordinated activity of
http://www.mmcjopt.org/
-
Miraj Medical Center Journal of Physiotherapy 2019 VOL 1 NO. 1 5 www.mmcjopt.org
the surrounding musculature. The
scapular muscles must dynamically
position the glenoid so that efficient
glenohumeral movement can occur.
When weakness or dysfunction of the
scapular musculature is present,
normal scapular positioning and
mechanics may become
altered.2 When the scapula fails to
perform its stabilization role, shoulder
complex function is inefficient, which
can result not only in decreased
neuromuscular performance but also
may predispose the individual to injury
of the glenohumeral joint.
Methods: The articles included were
searched in Databases like PubMed,
Cochrane and Google scholar. Articles
included were current approaches in
assessment and management of
scapular dyskinesis, Systematic
Reviews, Meta-analysis, Consensus
guidelines, Current Literature review. In
addition, the articles were also
manually checked for relevant articles
in peer reviewed journals. The search
terms were scapula, scapula
dyskinesis, scapular dysfunction,
scapular rehabilitation, and scapular
kinematic alteration.
Normal Scapula Biomechanics: The
scapula fulfils many roles to facilitate
optimal function of the shoulder. Its full
mobility is unlikely to be initially
appreciated due to its coverings of
muscles. The scapula’s only bony
articulation is with the clavicle at the AC
joint which acts as a bony strut for the
shoulder. There is no articulation with
the posterior thoracic wall. This lack of
congruency allows the scapula to be
mobile, allowing movements of
elevation, depression (superior
translation [ST]/inferior translation),
retraction, protraction (PRO), internal
rotation (IR)/external rotation,
anterior/posterior tilt, and upward
rotation (UR)/downward rotation. These
movements occur via a gliding motion
of the scapula on the thoracic cage
secondary to contraction of serratus
anterior and subscapularis.3
There are a number of muscles that
surround and insert to the scapula,
which can be divided functionally into
three groups.1 First, muscles that
contributes to scapula stability and
rotation-trapezius, rhomboids, levator
scapulae, and serratus anterior.
Second, the extrinsic muscles of the
glenohumeral joint, deltoid, biceps, and
triceps; and a third group of intrinsic
muscles, or the ‘‘shoulder protectors’’
comprising the rotator cuff muscles,
http://www.mmcjopt.org/
-
Miraj Medical Center Journal of Physiotherapy 2019 VOL 1 NO. 1 6 www.mmcjopt.org
supraspinatus, infraspinatus, teres
minor, and subscapularis.
Mechanically, the coordinated coupled
motion between the scapula and
humerus, often termed scapulohumeral
rhythm, is needed for efficient arm
movement and allows for glenohumeral
alignment in order to maximize joint
stability.4
McClure et al.5 found that during
scapular plane elevation of the arm in
normal subjects, there was a consistent
pattern of scapular upward rotation,
posterior tilting, and external rotation
along with clavicular elevation and
retraction.5 Scapular upward rotation is
the predominant scapulothoracic
motion. The motion of the scapula with
regard to changes in scapular internal
rotation angles shows more variability
across subjects, investigations, planes
of elevation, and point in the range of
motion of elevation.5-7 It has generally
been found that end range elevation
involves some scapulothoracic external
rotation, however, some studies report
internal rotation during elevation and
limited data are available.5
Pathomechanics: The scapular roles
can be altered by many anatomic
factors to create abnormal
biomechanics and physiology, both
locally and in the kinetic chain.
Most of the abnormal biomechanics
and overuse injuries that occur about
the shoulder girdle can be traced to
alterations in the function of the
scapular stabilizing muscles.8, 9
Altered scapular motion and position
have been termed scapular dyskinesis.
The definition of dyskinesis is the
alteration of normal scapular
kinematics.4 Many factors may
contribute to the development of
scapular dyskinesis including but not
limited to bony causes, including
posture (increased thoracic kyphosis)
or previous fracture (clavicle). Joint
causes including acromioclavicular joint
instability, acromioclavicular joint
arthrosis, and glenohumeral joint
internal derangement. Neurological
causes including cervical radiculopathy
or nerve palsy (long thoracic nerve or
spinal accessory nerve). Soft tissue
factors including inflexibity (tightness of
pectoralis minor) or intrinsic muscle
problems, and alterations in
periscapular muscle activation.
Discussion:
Scapular dyskinesis:
http://www.mmcjopt.org/
-
Miraj Medical Center Journal of Physiotherapy 2019 VOL 1 NO. 1 7 www.mmcjopt.org
Scapular dyskinesis is defined as
observable alterations in the position of
the scapula and the patterns of
scapular motion in relation to the
thoracic cage.10
‘Dys’ (alteration of ) ‘kinesis’ (motion) is
a general term that reflects the loss of
normal control of scapular motion.
Dyskinesis by itself is not a diagnosis.
Muscle inhibition or weakness is quite
common in glenohumeral pathology,
whether from instability, labral
pathology, or arthrosis.10-13
The serratus anterior and the lower
trapezius muscles are the most
susceptible to the effect of the
inhibition, and they are more frequently
involved in early phases of shoulder
pathology.14Muscle inhibition and
resulting scapular dyskinesis appear to
be a nonspecific response to a painful
condition in the shoulder rather than a
specific response to a certain
glenohumeral pathology.
This fact is supported by the finding of
scapular dyskinesis in as many as 68%
of patients with rotator cuff
abnormalities, 94% with labral tears,
and 100% with glenohumeral instability
problems.15, 16
Inhibition is seen as a decreased ability
of the muscles to exert torque and
stabilize the scapula as well as
disorganization of the normal muscle
firing patterns of the muscles around
the shoulder.12, 14 The exact nature of
this inhibition is not clear
Clinical assessment of Scapular
Dyskinesis: The goal of scapular
assessment is to identify abnormal
scapular motion or positioning,
determine any relationship between
altered motion and symptoms, and
identify underlying causative factors of
movement dysfunction.17-19
Clinical assessment of scapular
dyskinesis is inherently challenging due
to the 3-dimensional nature of scapular
movement and soft tissue surrounding
the scapula obscuring direct
measurement of bony positioning.
Clinical evaluation of scapular
dysfunction should include 3 basic
elements: (1) visual observation to
determine the presence or absence of
scapular dyskinesis in the symptomatic
patient; (2) the effect of manual
correction of dysfunction on symptoms;
and (3) evaluation of surrounding
anatomic structures that may be
responsible for dyskinesis
http://www.mmcjopt.org/
-
Miraj Medical Center Journal of Physiotherapy 2019 VOL 1 NO. 1 8 www.mmcjopt.org
The Lateral Scapular Slide Test is a
static measurement of the side-to-side
difference of the distance from the
inferior angle of the scapula to the
adjacent spinous process.20
The measures are performed with the
arms in 3 different positions and a side-
to-side difference of >1.5 cm should be
considered pathological. This test has
demonstrated fair to moderate levels of
reliability and is easily applied in a
clinical setting.21, 22
The major advantage of the lateral
scapular slide test is its ease of use in
the clinic. However, the validity of this
test has been questioned because of
the findings that both symptomatic and
asymptomatic individuals will
demonstrate asymmetry when
measured in this manner.22, 23
The static, and 2-dimensional nature of
this test fails to assess the dynamic 3-
dimensional scapular motion, Thus with
questionable validity of results requires
the use of other methods of scapular
assessment during clinical examination
Classification of Scapular
Dyskinesis:
Patterns of abnormal motion in scapular
dyskinesis are best observed by first
determining the position of the scapula
with the patient’s arms at rest at the
side, then by observing the scapular
motion as the arms are elevated and
lowered in the scapular plane.
These dyskinetic patterns fall into three
categories, which correspond to the
three planes of motion on the ellipsoid
thorax.24 This system can help identify
the type of abnormal scapular motion
and thus the rehabilitation required by
muscle strengthening and restoration of
flexibility. Type I is characterized by
prominence of the inferior medial
scapular border. This motion is
primarily abnormal rotation around a
transverse axis. Type II is characterized
by prominence of the entire medial
scapular border and represents
abnormal rotation around a vertical
axis. Type III is characterized by
superior translation of the entire
scapula and prominence of the superior
medial scapular border. The net effect
of the scapular dyskinetic patterns is an
adverse effect on the normal role of the
scapula in shoulder function.20
Scapula dyskinesis test (SDT):
The patient is asked to flex and abduct
their shoulder while carrying light
weights.25 He or she performed 3
repetitions of bilateral weighted flexion
and weighted abduction. The tests
http://www.mmcjopt.org/
-
Miraj Medical Center Journal of Physiotherapy 2019 VOL 1 NO. 1 9 www.mmcjopt.org
were performed with participants
grasping dumbbells, using 1.4 kg (3 lb)
for those weighing less than 68.1 kg
(150 lb) and 2.3 kg (5 lb) for those
weighing 68.1 kg or more.
The therapist then observes to see if
there is any protrusion of the
medial/inferior borders of the scapula
away from the thorax sometimes
referred to as winging; however, it is not
a true winged scapula as seen in long
thoracic nerve palsy. Visual
assessment offers an alternative to
linear measures for evaluating 3-D
scapular motion in a practical clinical
method that incorporates dynamic
upper extremity tasks that require both
raising (concentric) and lowering
(eccentric) phases
Uncoordinated movements, such as
early/late scapula elevation and
stuttering, also are noted. This test uses
the visually altered 3D kinematics of the
scapula in dyskinetic shoulders. A
second group of authors 26 modified the
same test, by assessing defined
parameters, recording any positive
findings as a yes, and normal findings
as a no. This is currently the gold
standard for observational testing.4, 17
Rating Scale
Each test movement (flexion and
abduction) rated as
a) Normal motion: no evidence of
abnormality
b) Subtle abnormality: mild or
questionable evidence of abnormality,
not consistently present
c) Obvious abnormality: striking, clearly
apparent abnormality, evident on at
least 3/5 trials (dysrhythmias or winging
of 1 in [2.54 cm] or greater
Displacement of scapula from thorax)
Final rating is based on combined
flexion and abduction test
movements.
Normal: Both test motions are rated as
normal or 1 motion is rated as normal
and the other as having subtle
abnormality.
Subtle abnormality: Both flexion and
abduction are rated as having subtle
abnormalities.
Obvious abnormality: Either flexion or
abduction is rated as having obvious
abnormality.
The corrective maneuvres of
scapula: Several examination methods
are intended to passively alter the
position of the scapula to assess
http://www.mmcjopt.org/
-
Miraj Medical Center Journal of Physiotherapy 2019 VOL 1 NO. 1 10 www.mmcjopt.org
change in shoulder muscle strength,
pain, or both, compared to the natural
unassisted condition during arm
elevation. Both the scapular retraction27
and reposition tests28 have been shown
to influence muscle strength, but the
influence of these on scapular position
has not been studied
Scapula assistance test (SAT): The
SAT was initially performed with the
examiner manually assisting the
scapula into upward rotation by pushing
the inferior medial border of the scapula
as the patient elevated the arm, 20 and
has since been described to include
manual assistance into both upward
rotation and posterior tilt.29 In theory,
the SAT alters the position of the
scapula, increases subacromial space,
and may influence rotator cuff muscle
strength in individuals with SAIS.
Scapular repositioning test (SRT): In
SRT the examiner emphasized
posterior tilting and external rotation of
the scapula but avoiding full retraction
and named it the Scapula Reposition
Test. With the application of a manual
repositioning maneuver, the patients’
symptoms were reduced. Manual
repositioning of the scapula
significantly increased strength in a
subgroup of athletes, regardless of the
absence or presence of impingement
symptoms. The SRT is a simple clinical
test that may potentially be useful in an
impairment based classification
approach to shoulder problems. The
scapula reposition test may be a way to
identify athletes most suitable for
interventions addressing the scapula,
such as strengthening, taping, or
bracing.
Treatment of Scapular Dyskinesis:
Most of the abnormalities in scapular
motion or position can be treated by
physical therapy to relieve the
symptoms associated with inflexibility
or trigger points and to re-establish
muscle strength and activation
patterns.20, 30
During the physical examination, the
therapist should address all possible
deficiencies found on different levels of
the kinetic chain. Based on the results
of clinical assessment, appropriate
treatment goals should be set leading to
proper rehabilitation strategies.
There is some support for the use of
scapular-focused exercise therapy in
patients with SPS (Subacromial pain
syndrome). Owing to the low number of
studies, more randomised controlled
trials are needed to determine the
http://www.mmcjopt.org/
-
Miraj Medical Center Journal of Physiotherapy 2019 VOL 1 NO. 1 11 www.mmcjopt.org
clinical outcomes of scapular-focused
exercise therapy.31
In another study, adults with SPS,
scapular focused interventions can
improve short-term shoulder pain and
function.32
An analysis by two recent systematic
reviews 31,33 indicated some support for
scapular-focused exercise approaches,
although the evidence was either
conflicting or below clinical significance
for variables such as pain, scapula
position/movement, range of motion,
and rotator cuff strength.
Another study emphasized conscious
correction of scapular orientation34.The
proposed strengthening and motor
control protocol was determined
through the selection of exercises
focused on the scapulothoracic joint
and periscapular muscles that are used
in clinical practice.35
There is no consensus with regard to
neuromuscular control exercises, and
for this reason, exercises that included
visual, auditory, or kinesthetic feedback
were used, with an emphasis on the
retraction of the scapula during their
execution.
In the selection of rehabilitation
exercises, the clinician should have a
preference for exercises with high
activation of the LT and MT and low
activity of the UT.36 The figure 1 gives
the scope of scapular rehabilitation in
management of shoulder pain.
Fig 1 Scapular Rehabilitation Algorithm (Cools et al36)
Summary of common Interventions:
http://www.mmcjopt.org/
-
Miraj Medical Center Journal of Physiotherapy 2019 VOL 1 NO. 1 12 www.mmcjopt.org
Table No 1
Pathologic states Scapular
kinematic
alterations
Proposed Biomechanical Mechanisms of
Scapular Kinematic Deviations7
Impingement or
Rotator Cuff Disease
Lesser upward
rotation, Lesser
posterior tilting,
Greater internal
rotation
Associated
effects:
Lesser scapular
upward rotation
and posterior
tilt
Mechanism:
Inadequate
serratus
activation
Intervention
Serratus anterior
strengthening or
retraining37-39
Glenohumeral Joint
Instability
Lesser upward
rotation, Greater
internal rotation
Greater
clavicular
elevation
Excess upper
trapezius
activation
Upper trapezius
activation
reduction40
Adhesive Capsulitis Greater upward
rotation
Greater
scapular
internal
rotation and
anterior tilt
Pectoralis
minor tightness
Pectoralis minor
stretching41,42
Greater
scapular
anterior tilt
Posterior
glenohumeral
joint soft tissue
tightness
Posterior shoulder
stretching43,44
Greater
scapular
internal
rotation and
anterior tilt,
lesser scapular
upward
rotation
Thoracic
kyphosis or
flexed posture
Thoracic extension
posture and
exercise45
http://www.mmcjopt.org/
-
Miraj Medical Center Journal of Physiotherapy 2019 VOL 1 NO. 1 13 www.mmcjopt.org
Rehabilitation for scapular dyskinesis
should start proximally and end distally.
It should include the whole kinetic chain
rehabilitation. The ultimate goal of
physical therapy is to achieve the
position of optimal scapular function.
The sequence of rehabilitation
exercises may need to be adapted for
individual cases based on the rate of
progress at each specific stage.
The biomechanical analysis of
rehabilitation exercises has gained
recent attention. Advances in the
understanding of the biomechanical
factors of rehabilitation have led to the
enhancement of rehabilitation
programs that seek to facilitate
recovery, while placing minimal strain
on specific healing structures. The
summary of intervention is given in
Table 1.
There is need to study the influence of
scapular dyskinesis in long term in
normal as well as various clinical
scenarios/patients. The impact of
integration of the whole-body kinetic-
chain approach to strengthening and
rehabilitating injuries needs
consideration. The impact of
multiplanar movement in addition and
strength, posture, balance (stable and
dynamic surface, and neuromuscular
control are all vital components to any
injury prevention of rehabilitation
program. Thus, integrated approach to
scapular rehabilitation can be used by
the therapist to design appropriate
rehabilitation and injury prevention
programs. Wilmore and Smith propose
a paradigm shift (Fig 2) whereby
scapular dyskinesia is seen not in
isolation but is considered within the
broader context of patient-centred care
and an entire neuromuscular system.
Fig 2: Scapular dyskinesis:
traditional model versus a
symptoms and systems-based
approach (Wilmore and Smith).
Conclusions: Scapular dyskinesis is
common entity in shoulder pain. Use of
http://www.mmcjopt.org/
-
Miraj Medical Center Journal of Physiotherapy 2019 VOL 1 NO. 1 14 www.mmcjopt.org
valid measure to clinically assess
scapular dyskinesis is important.
However, the various associated
factors need to be studied to identify
movement system impairments. The
movement system is the core
competency of the physical therapist. It
is therefore important to identify the
prime glenohumeral and scapular
movement dysfunction with sound
clinical decision making process. This
will enhance patient management with
appropriate exercise programs for
injury rehabilitation and prevention.
References:
1. Paine RM, Voight M. The role of the
scapula.J. Orthop. Sports Phys.
Ther.1993; 18:386-91.
2. Voight ML, Thomson BC. The role of
the scapula in the rehabilitation of
shoulder injuries. J Athl Training. 2000;
35(3):364–372
3. Peat M. Functional anatomy of the
shoulder complex.Phys. Ther.1986;
66:1855-65.
4. Kibler WB, Ludewig PM, McClure
PW,et al. Clinical implications of
scapular dyskinesis in shoulder injury:
The 2013 consensus statement from
the Scapular Summit.Br. J. Sports
Med.2013; 47:877-85.
5. McClure PW, Michener LA, Sennett
BJ, Karduna AR. Direct 3-dimesional
measurement of scapular kinematics
during dynamic movements in vivo. J
Shoulder Elbow Surg. 2001; 10:269-
277.
6. Borstad JD, Ludewig PM.
Comparison of scapular kinematics
between elevation and lowering of the
arm in the scapular plane. Clin
Biomech. 2002; 17: 650-659.
7. Ludewig PM, Reynolds JF. The
association of scapular kinematics and
glenohumeral joint pathologies. J
Orthop Sports Phys Ther. 2009; 39: 90-
104.
8. Moseley JB Jr, Jobe FW, Pink M,
Perry J, Tibone JE. EMG analysis of the
scapular muscles during a scapular
rehabilitation program. Am J Sports
Med. 1992; 20:128–134.
9. Kuhn JE, Plancher KD, Hawkins
RJ. Scapular winging. J Am Acad
Orthop Surg. 1995; 3:319–325.
10. Warner JJ, Micheli LJ, Arslanian LE,
Kennedy J, Kennedy R:
Scapulothoracic motion in normal
shoulders and shoulders with
glenohumeral instability and
impingement syndrome: A study using
http://www.mmcjopt.org/
-
Miraj Medical Center Journal of Physiotherapy 2019 VOL 1 NO. 1 15 www.mmcjopt.org
Moire topographic analysis. Clin
Orthop1992; 285:191-199.
11. Fleisig GS, Barrentine SW,
Escamilla RF, Andrews JR:
Biomechanics of overhand throwing
with implications for injuries. Sports
Med1996; 21:421-437.
12. McQuade KJ, Dawson J, Smidt GL:
Scapulothoracic muscle fatigue
associated with alterations in
scapulohumeral rhythm kinematics
during maximum resistive shoulder
elevation. J Orthop Sports Phys
Ther1998; 28:74-80.
13. Glousman R, Jobe F, Tibone J,
MoynesD, Antonelli D, Perry J:
Dynamic electromyographic analysis of
the throwing shoulder with
glenohumeral instability.J Bone Joint
Surg Am1988; 70:220-226.
14. McClure PW, Michener LA, Sennett
BJ, Karduna AR: Direct 3-dimensional
measurement of scapular kinematics
during dynamic movements in vivo. J
Shoulder Elbow Surg2001; 10:269-277.
15. Paletta GA Jr, Warner JJ, Warren
RF, Deutsch A, Altchek DW: Shoulder
kinematics with two-plane x-ray
evaluation in patients with anterior
instability or rotator cuff tearing. J
Shoulder Elbow Surg1997; 6:516-527
16. Burkhart SS, Morgan CD, Kibler
WB: Shoulder injuries in overhead
athletes: The “dead arm” revisited. Clin
Sports Med2000; 19:125-158
17. Kibler WB, Ludewig PM, McClure P,
et al. Scapular Summit 2009:
introduction. July 16, 2009, Lexington,
Kentucky. J Orthop Sports Phys Ther.
2009; 39:A1–A13.
18. Kibler WB, Sciascia A. Current
concepts: scapular dyskinesis. Br J
Sports Med. 2010; 44:300–305.
19. Tate AR, McClure PW. Examination
and management of scapular
dysfunction. In: Skirven TM,
ed.Rehabilitation of the Hand and
Upper Extremity. Philadelphia, PA:
Mosby/Elsevier; 2010.
20. Kibler WB. Role of the scapula in
athletic shoulder function. Am J Sports
Med. 1998; 26:325–337.
21. Odom CJ, Taylor AB, Hurd CE, et
al. Measurement of scapular
asymmetry and assessment of
shoulder dysfunction using the Lateral
Scapular Slide Test: a reliability and
validity study.Phys Ther. 2001; 81:799–
809.
22. Koslow PA, Prosser LA, Strony GA,
et al. Specificity of the lateral scapular
http://www.mmcjopt.org/
-
Miraj Medical Center Journal of Physiotherapy 2019 VOL 1 NO. 1 16 www.mmcjopt.org
slide test in asymptomatic competitive
athletes.J Orthop Sports Phys Ther.
2003; 33:331–336.
23. Nijs J, Roussel N, Vermeulen K, et
al. Scapular positioning in patients with
shoulder pain: a study examining the
reliability and clinical importance of 3
clinical tests. Arch Phys Med Rehabil.
2005; 86:1349–1355.
24. Kibler WB, Uhl TL, Maddux JW,
Brooks PV, Zeller B, McMullen J:
Qualitative clinical evaluation of
scapular dysfunction: A reliability study.
J Shoulder Elbow Surg2002; 11:550-
556.
25. McClure P, Tate AR, Kareha S, et
al. A clinical method for identifying
scapular dyskinesis, part 1: reliability.J.
Athl. Train.2009; 44:160-4
26. Uhl TL, Kibler WB, Gecewich B,
Tripp BL. Evaluation of clinical
assessment methods for scapular
dyskinesis. Arthroscopy. 2009;
25:1240-8.
27. Kibler WB, Sciascia A, Dome D.
Evaluation of apparent and absolute
supraspinatus strength in patients with
shoulder injury using the scapular
retraction test. Am J Sports Med. 2006;
34:1643-1647
28. Tate AR, McClure PW, Kareha S,
Irwin D. Effect of the Scapula
Reposition Test on shoulder
impingement symptoms and elevation
strength in overhead athletes. J Orthop
Sports Phys Ther. 2008; 38:4-11
29. Rabin A, Irrgang JJ, Fitzgerald GK,
Eubanks A. The intertester reliability of
the scapular assistance test. J Orthop
Sports Phys Ther. 2006; 36:653-660
30. Kibler WB: Evaluation and
diagnosis of scapulothoracic problems
in the athlete.
Sports Medicine and Arthroscopic
Review 2000; 8:192-202
31.
Reijneveld EAE, Noten S, Michener LA
, et al Clinical outcomes of a scapular-
focused treatment in patients with
subacromial pain syndrome: a
systematic review British Journal of
Sports Medicine 2017; 51:436-441.
32. Hiroki Saito, Meg E. Harrold,
Vinicius Cavalheri & Leanda
McKenna (2018) Scapular focused
interventions to improve shoulder pain
and function in adults with subacromial
pain: A systematic review and meta-
analysis, Physiotherapy Theory and
Practice, 34:9, 653-670
http://www.mmcjopt.org/
-
Miraj Medical Center Journal of Physiotherapy 2019 VOL 1 NO. 1 17 www.mmcjopt.org
33. Bury, J., West, M., Chamorro-
Moriana, G., Littlewood, C., 2016.
Effectiveness of scapula focused
approaches in patients with rotator cuff
related shoulder pain: a systematic
review and meta-analysis. Man. Ther.
25, 35–42
34.De Mey, K., Danneels, L.A., Cagnie,
B., Huyghe, L., Seyns, E., Cools, A.M.,
2013.Conscious correction of scapular
orientation in overhead athletes
performing selected shoulder
rehabilitation exercises: the effect on
trapezius muscle activation measured
by surface electromyography. J.
Orthop. Sports Phys. Ther. 43, 3–10
35. Reinold, M.M., Escamilla, R.F.,
Wilk, K.E., 2009. Current concepts in
the scientific and clinical rationale
behind exercises for glenohumeral and
scapulothoracic musculature. J.
Orthop. Sports Phys. Ther. 39, 105–
117
36.Cools AMJ, Struyf F, De Mey K, et
al Rehabilitation of scapular dyskinesis:
from the office worker to the elite
overhead athlete British Journal of
Sports Medicine 2014;48:692-697.
37. Decker MJ, Hintermeister RA,
Faber KJ, Hawkins RJ. Serratus
anterior muscle activity during selected
rehabilitation exercises. Am J Sports
Med. 1999; 27:784-791.
38. Ekstrom RA, Donatelli RA,
Soderberg GL. Surface
electromyographic analysis of
exercises for the trapezius and serratus
anterior muscles.J Orthop Sports Phys
Ther.2003; 33:247-258
39. Hardwick DH, Beebe JA, McDonnell
MK, LangCE. A comparison of serratus
anterior muscle activation during a wall
slide exercise and other traditional
exercises.J Orthop Sports Phys The
2006; 36:903-910
40.Cools AM, Dewitte V, Lanszweert F,
et al.Rehabilitation of scapular muscle
balance: which exercises to
prescribe?Am J Sports Med2007; 35:
1744–1751
41. Borstad JD, Ludewig PM. The effect
of long versus short pectoralis minor
resting length on scapular kinematics in
healthy individuals. J Orthop Sports
Phys Ther2005; 35:227–38.
42. Borstad JD. Resting position
variables at the shoulder: evidence to
support aposture-impairment
association.Phys Ther2006; 86:549–
57.
http://www.mmcjopt.org/
-
Miraj Medical Center Journal of Physiotherapy 2019 VOL 1 NO. 1 18 www.mmcjopt.org
43 Tyler TF, Nicholas SJ, Roy T,et al.
Quantification of posterior capsule
tightness and motion loss in patients
with shoulder impingement. Am J
Sports Med 2000; 28:668–73.
44 Tyler TF, Nicholas SJ, Lee SJ,et al.
Correction of posterior shoulder
tightness is associated with symptom
resolution in patients with internal
impingement. Am J Sports Med2010;
38:114–19
45. Won-gyu Yoo.Effects of thoracic
posture correction exercises on
scapular position. J Phys Ther Sci.
2018 Mar; 30(3): 411–412.
46. Elaine G Willmore and Michael J
Smith. Scapular dyskinesia: evolution
towards a systems-based approach.
Shoulder & Elbow 2016, Vol. 8(1) 61–
70
http://www.mmcjopt.org/https://www.ncbi.nlm.nih.gov/pubmed/?term=Yoo%20Wg%5BAuthor%5D&cauthor=true&cauthor_uid=29581661https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5857448/
There are a number of muscles that surround and insert to the scapula, which can be divided functionally into three groups.1 First, muscles that contributes to scapula stability and rotation-trapezius, rhomboids, levator scapulae, and serratus anterio...Mechanically, the coordinated coupled motion between the scapula and humerus, often termed scapulohumeral rhythm, is needed for efficient arm movement and allows for glenohumeral alignment in order to maximize joint stability.4McClure et al.5 found that during scapular plane elevation of the arm in normal subjects, there was a consistent pattern of scapular upward rotation, posterior tilting, and external rotation along with clavicular elevation and retraction.5 Scapular up...Pathomechanics: The scapular roles can be altered by many anatomic factors to create abnormal biomechanics and physiology, both locally and in the kinetic chain.3. Peat M. Functional anatomy of the shoulder complex.Phys. Ther.1986; 66:1855-65.4. Kibler WB, Ludewig PM, McClure PW,et al. Clinical implications of scapular dyskinesis in shoulder injury: The 2013 consensus statement from the Scapular Summit.Br. J. Sports Med.2013; 47:877-85.5. McClure PW, Michener LA, Sennett BJ, Karduna AR. Direct 3-dimesional measurement of scapular kinematics during dynamic movements in vivo. J Shoulder Elbow Surg. 2001; 10:269-277.6. Borstad JD, Ludewig PM. Comparison of scapular kinematics between elevation and lowering of the arm in the scapular plane. Clin Biomech. 2002; 17: 650-659.7. Ludewig PM, Reynolds JF. The association of scapular kinematics and glenohumeral joint pathologies. J Orthop Sports Phys Ther. 2009; 39: 90-104.45. Won-gyu Yoo.Effects of thoracic posture correction exercises on scapular position. J Phys Ther Sci. 2018 Mar; 30(3): 411–412.46. Elaine G Willmore and Michael J Smith. Scapular dyskinesia: evolution towards a systems-based approach. Shoulder & Elbow 2016, Vol. 8(1) 61–70