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The scapula: stabilize or mobilize?
Approaches to achieve scapular control
Dr Ann Cools, PT, PhDDept Rehab. Sciences & PhysiotherapyGhent University, Belgium 1Ann Cools Wrightington Nov 2012
Ghent University, Faculty of Medicine & Health Sciences, Dept of Rehabilitation Sciences & Physiotherapy
Supervisor: Prof dr Ann Cools
Researchers:
- Kristof De Mey
- Annelies Maenhout
- Annemie Van de Velde
- Maarten Van HerzeeleAnn Cools Wrightington Nov 2012 2
Scapular dyskinesis in relation to shoulderpain: scientific evidence
Ann Cools Wrightington Nov 2012
Ludewig 2000, Lukasiewicz 1999, Warner 1992, , McClure 2006, Endo 2001, Hebert 2002, Lin 2006,Laudner 2006, Su 2004, Kibler 2009,Mc Clure 2009, Tate 2009 3
Implications of scapulardyskinesis on daily activities….
Ann Cools Wrightington Nov 2012 4
Need for science-based scapularrehab program….
Scapular Rehab AlgorithmLack of
Soft-tissue flexibilityLack of
Muscle performance
Scapular muscles GH muscles/capsule Muscle Control Muscle Strength
- Levator scapulae- pectoralis minor
- infraspinatus- posterior capsule
- co-contraction- force couples
- lower/middle trap- serratus anterior
STRETCHING & MOBILISATIONNEUROMUSCULARCOORDINATION
STRENGTH TRAINING
Advanced controlDuring basic activities
Endurance/strength
Balance -ratio
Advanced controlDuring sports
Conscious musclecontrol
Conscious musclecontrol- Manual stretching
- home stretching- soft tissue techniques- manual mobilisations (accessory movements)-MWM
(Ellenbecker & Cools, BJSM 2010)
5Ann Cools Wrightington Nov 2012
Scapular Rehab AlgorithmLack of
Soft-tissue flexibilityLack of
Muscle performance
Scapular muscles GH muscles/capsule Muscle Control Muscle Strength
- Levator scapulae- pectoralis minor
- infraspinatus- posterior capsule
- co-contraction- force couples
- lower/middle trap- serratus anterior
STRETCHING & MOBILISATIONNEUROMUSCULARCOORDINATION
STRENGTH TRAINING
Advanced controlDuring basic activities
Endurance/strength
Balance -ratio
Advanced controlDuring sports
Conscious musclecontrol
Conscious musclecontrol- Manual stretching
- home stretching- soft tissue techniques- manual mobilisations (accessory movements)-MWM
(Ellenbecker & Cools, BJSM 2010)
6Ann Cools Wrightington Nov 2012
Scapular Rehab AlgorithmLack of
Soft-tissue flexibilityLack of
Muscle performance
Scapular muscles GH muscles/capsule Muscle Control Muscle Strength
- Levator scapulae- pectoralis minor
- infraspinatus- posterior capsule
- co-contraction- force couples
- lower/middle trap- serratus anterior
STRETCHING & MOBILISATIONNEUROMUSCULARCOORDINATION
STRENGTH TRAINING
Advanced controlDuring basic activities
Endurance/strength
Balance -ratio
Advanced controlDuring sports
Conscious musclecontrol
Conscious musclecontrol- Manual stretching
- home stretching- soft tissue techniques- manual mobilisations (accessory movements)-MWM
(Ellenbecker & Cools, BJSM 2010)
7Ann Cools Wrightington Nov 2012
Scapular Rehab AlgorithmLack of
Soft-tissue flexibilityLack of
Muscle performance
Scapular muscles GH muscles/capsule Muscle Control Muscle Strength
- Levator scapulae- pectoralis minor
- infraspinatus- posterior capsule
- co-contraction- force couples
- lower/middle trap- serratus anterior
STRETCHING & MOBILISATIONNEUROMUSCULARCOORDINATION
STRENGTH TRAINING
Advanced controlDuring basic activities
Endurance/strength
Balance -ratio
Advanced controlDuring sports
Conscious musclecontrol
Conscious musclecontrol- Manual stretching
- home stretching- soft tissue techniques- manual mobilisations (accessory movements)-MWM
(Ellenbecker & Cools, BJSM 2010)
8Ann Cools Wrightington Nov 2012
Scapular Rehab AlgorithmLack of
Soft-tissue flexibilityLack of
Muscle performance
Scapular muscles GH muscles/capsule Muscle Control Muscle Strength
- Levator scapulae- pectoralis minor
- infraspinatus- posterior capsule
- co-contraction- force couples
- lower/middle trap- serratus anterior
STRETCHING & MOBILISATIONNEUROMUSCULARCOORDINATION
STRENGTH TRAINING
Advanced controlDuring basic activities
Endurance/strength
Balance -ratio
Advanced controlDuring sports
Conscious musclecontrol
Conscious musclecontrol- Manual stretching
- home stretching- soft tissue techniques- manual mobilisations (accessory movements)-MWM
(Ellenbecker & Cools, BJSM 2010)
9Ann Cools Wrightington Nov 2012
STRETCHING PECT MINOR: literature versus reality
(Borstad JOSPT 2006, Reeser PM&R 2010, Ellenbecker & Cools BJSM 2010)10Ann Cools Wrightington Nov 2012
Ann Cools Wrightington Nov 2012 11
PM lengthMeasurement 2
PM lengthMeasurement 3
Swim training session
ANGULAR STRETCHING
DIRECT MANUAL
STRETCHING
Annemie Van de Velde, Karen D’Huyvetter, Céline Dufour, Ann Cools: Effect of two stretching techniques on the length of the pectoralis minor in adolescent swimmers . Paper in progress, 2012
PM lengthMeasurement 1
Adolescent swimmers (N=29, mean age = 14y)
3x 30” stretching,
PM length measurement (Borstad et al. 2005)
Ann Cools Wrightington Nov 2012 12
Annemie Van de Velde, Karen D’Huyvetter, Céline Dufour, Ann Cools: Effect of two stretching techniques on the length of the pectoralis minor in adolescent swimmers . Paper in progress, 2012
Scapular Rehab AlgorithmLack of
Soft-tissue flexibilityLack of
Muscle performance
Scapular muscles GH muscles/capsule Muscle Control Muscle Strength
- Levator scapulae- pectoralis minor
- infraspinatus- posterior capsule
- co-contraction- force couples
- lower/middle trap- serratus anterior
STRETCHING & MOBILISATIONNEUROMUSCULARCOORDINATION
STRENGTH TRAINING
Advanced controlDuring basic activities
Endurance/strength
Balance -ratio
Advanced controlDuring sports
Conscious musclecontrol
Conscious musclecontrol- Manual stretching
- home stretching- soft tissue techniques- manual mobilisations (accessory movements)-MWM
(Ellenbecker & Cools, BJSM 2010)
13Ann Cools Wrightington Nov 2012
Ann Cools Wrightington nov 2012
Stretching posterior shoulder: clinical experience
� Sleeper’s stretch & cross body stretch improve ROM (Mc Clure2005)
� Additional manual mobilisationsimprove ROM (Manske 2010)
� Improvement ROM is related to reduction of symptoms (Tyler 2010)
� Stretching has a positiveinfluence on the subacromialspace (Maenhout 2012)
15Ann Cools Wrightington Nov 2012
POSTERIOR SHOULDER STRETCHING
Ann Cools Wrightington Nov 2012
Scientific Evidence? comparisontranslation – angular stretching
Angular stretching Translation mobilisation
(patients with GIRD: n=30, healthy shoulders with GIRD: n=30)
(Cools et al. Shoulder & Elbow 2011)
16
RESULTS:
� Significant increase in ROM after 3w
� Equal results both techniques
� Significant pain reduction in patientgroup
Ann Cools Wrightington Nov 2012
angular stretching
20
40
60
80
before after 3wlater
degr
ee D patients
D controls
ND patients
ND controls
translation mobilisations
20
40
60
80
before after 3wlater
degr
ee
D patients
D controls
ND patients
ND controls
(Cools et al. Shoulder & Elbow 2011)
VAS BeforeBeforeBeforeBefore----afterafterafterafter
AfterAfterAfterAfter----3w 3w 3w 3w laterlaterlaterlater
Pain/movement p= 0,001p= 0,001p= 0,001p= 0,001 p= 0,042
Hawkins’ test p= 0,001p= 0,001p= 0,001p= 0,001 p= 0,116
Neer’s test p= 0,002p= 0,002p= 0,002p= 0,002 p= 0,223
Apprehension p= 0,022 p= 0,755
Modified Rowe p= 0,001p= 0,001p= 0,001p= 0,001 p= 0,125
17
Scapular Rehab AlgorithmLack of
Soft-tissue flexibilityLack of
Muscle performance
Scapular muscles GH muscles/capsule Muscle Control Muscle Strength
- Levator scapulae- pectoralis minor
- infraspinatus- posterior capsule
- co-contraction- force couples
- lower/middle trap- serratus anterior
STRETCHING & MOBILISATIONNEUROMUSCULARCOORDINATION
STRENGTH TRAINING
Advanced controlDuring basic activities
Endurance/strength
Balance -ratio
Advanced controlDuring sports
Conscious musclecontrol
Conscious musclecontrol- Manual stretching
- home stretching- soft tissue techniques- manual mobilisations (accessory movements)-MWM
(Ellenbecker & Cools, BJSM 2010)
18Ann Cools Wrightington Nov 2012
Ann Cools Wrightington Nov 2012
Conscious muscle control lowertrapezius: Scapular Orientation Exercise
� Subjects are able to perform consistent movements of the scapula into posterior tilt and upward rotation
� Significant increase scapular muscleactivity in trapezius
� High correlation betweenassisted and unassisted(home) exercise
(Mottram 2009)19
Ann Cools Wrightington Nov 2012
Sidelying Forward flexion Sidelying Ext Rotation
Prone Hor Abd + Ext Rot Prone Extension
20
Scapular Orientation Exercise
Does conscious correction of scapular positioning influence muscle activity during exercises?
Yes, for 2 out of the 4 exercises
Ann Cools Wrightington Nov 2012
De Mey K., Conscious correction of scapular orientation in overhead athletes performing selected
shoulder rehabilitation exercises: what´s the effect on trapezius muscle activation measured by surface electromyography? JOSPT Under revision July 2012
21
Flexibility versus musclerecruitment problems?
Ann Cools Wrightington Nov 2012 22
Scapular Rehab AlgorithmLack of
Soft-tissue flexibilityLack of
Muscle performance
Scapular muscles GH muscles/capsule Muscle Control Muscle Strength
- Levator scapulae- pectoralis minor
- infraspinatus- posterior capsule
- co-contraction- force couples
- lower/middle trap- serratus anterior
STRETCHING & MOBILISATIONNEUROMUSCULARCOORDINATION
STRENGTH TRAINING
Advanced controlDuring basic activities
Endurance/strength
Balance -ratio
Advanced controlDuring sports
Conscious musclecontrol
Conscious musclecontrol- Manual stretching
- home stretching- soft tissue techniques- manual mobilisations (accessory movements)-MWM
(Ellenbecker & Cools, BJSM 2010)
23Ann Cools Wrightington Nov 2012
Ann Cools Wrightington Nov 2012
Sidelying Forward flexion Sidelying External Rotation
Prone Hor Abd + Ext Rot Prone Extension
24
SCAPULAR STRENGTH TRAINING:Scientific evidence healthy people
A 12 week program of scapular exercises improves isokineticmuscle strength, and muscle balance in healthy adolescent swimmers
Ann Cools Wrightington Nov 2012 25
SCAPULAR STRENGTH TRAINING:Scientific evidence healthy people
6 month program of scapular retraction exercises improvesRC strength (infraspinatus) in volleyball players
Ann Cools Wrightington Nov 201226
SCAPULAR STRENGTH TRAINING:Scientific evidence patients
Scapular exercises improve muscle strength, symptoms and relative muscle activity in overhead athletes with impingement symptoms
Ann Cools Wrightington Nov 2012 27
Ann Cools Wrightington Nov 2012
Scapular Rehab AlgorithmLack of
Soft-tissue flexibilityLack of
Muscle performance
Scapular muscles GH muscles/capsule Muscle Control Muscle Strength
- Levator scapulae- pectoralis minor
- infraspinatus- posterior capsule
- co-contraction- force couples
- lower/middle trap- serratus anterior
STRETCHING & MOBILISATIONNEUROMUSCULARCOORDINATION
STRENGTH TRAINING
Advanced controlDuring basic activities
Endurance/strength
Balance -ratio
Advanced controlDuring sports movements
Conscious musclecontrol
Conscious musclecontrol
- Manual stretching- home stretching- soft tissue rechniques- manual mobilisations (accessory movements)
(Ellenbecker & Cools, BJSM 2010)28
FUNCTIONAL EXERCISES: literature
� Integrate kinetic chain intoshoulder rehab exercises
� Focus on open and closedchain exercises
� Challenge sports specificpositions and movements
(Kibler AJSM 1998, Lintner Sports Med 2008, Cools BJSM 2008)
Ann Cools Wrightington Nov 2012 29
Ann Cools Wrightington Nov 2012
Background and purpose of the studies:
� Maenhout et al. BJSM 2009:
lower extremity positioninfluences scapular musclerecruitment and muscle balanceratios in closed kinetic chainexercises
� De Mey et al. Accepted for publication JSAMS May
2012: trunk & lower extremityposition and movement influencescapular muscle recruitment and muscle balance ratios in openkinetic chain exercises 30
Results (1): EMG activity scapularmuscles: extension contralateralleg versus other modalities
UT MT LT SA
Ex Mean StD Mean SD Mean SD Mean SD
1 13,63 7,27 10,37 5,38 11,30 6,33 31,65 19,11
2 18,31 13,17 14,55 8,28 20,12 10,07 23,43 14,66
3 16,18 8,32 13,04 7,91 11,80 8,14 44,20 18,67
4 13,67 8,00 10,11 5,42 10,44 5,90 25,30 15,77
5 16,69 10,55 13,14 6,00 16,86 9,27 14,27 8,14
6 14,39 7,67 11,44 6,69 10,75 6,68 30,46 15,60
7 17,20 10,52 12,30 6,22 10,72 6,53 36,71 15,55
(Maenhout & Cools, BJSM 2009)31Ann Cools Wrightington Nov 2012
Ann Cools Wrightington Nov 2012
Results (2): EMG activity scapularmuscles: unilateral squat versus other exercise modalities
00,5
11,5
22,5
33,5
44,5
5
Zit
Stan
d
Squa
t
Lun
ge
Squa
tdy
nam
isch
Lun
gedy
nam
isch
Uni
poda
leSq
uat
dyna
mis
chUitvoeringsmodaliteiten
Gem
idde
ld (%
MV
C)
Bilateraal
Unilateraal
* *
**
*
*= significant main effect “exercise”(De Mey & Cools, JSAMS 2012)
32
Ann Cools Wrightington Nov 2012
Diagonals in CK exercises
33
Ann Cools Wrightington Nov 2012
Scapular Rehab AlgorithmLack of
Soft-tissue flexibilityLack of
Muscle performance
Scapular muscles GH muscles/capsule Muscle Control Muscle Strength
- Levator scapulae- pectoralis minor
- infraspinatus- posterior capsule
- co-contraction- force couples
- lower/middle trap- serratus anterior
STRETCHING & MOBILISATIONNEUROMUSCULARCOORDINATION
STRENGTH TRAINING
Advanced controlDuring basic activities
Endurance/strength
Balance -ratio
Advanced controlDuring sports movements
Conscious musclecontrol
Conscious musclecontrol
- Manual stretching- home stretching- soft tissue rechniques- manual mobilisations (accessory movements)
(Ellenbecker & Cools, BJSM 2010)
34
Influence of experimentally induced pain in the supraspinatus on scapular muscle activity(Van Herzeele M, Parlevliet T, HeemanS , Hofman K & Cools A, unpublished data 2012)
- ultrasound-controlled pain induction (hypertonic saline) in supraspinatus muscle (N=23)
- Pain sensation Numeric Rating Scale (NRS) >6/10
- Elevation in 3 planes before and after paininduction- Before pain
- Immediately after pain induction
- 20’ after pain induction (NRS 0,62)
- EMG scapular muscles (Noraxon Myoresearch)- Normalised EMG activity (% MVC)
- Recruitment order
Ann Cools Wrightington Nov 2012 35
Level of activityDURING pain Total
movementConcentricphase
Eccentricphase
abduction Increased LT activity 3,52%
Scapularelevation
Decreased LTactivity 1,8%
Forward flexion Increased SA activity 17%
Decreased SA activity 1,49%
Ann Cools Wrightington Nov 2012 36
20’ after pain Total movement
Concentricphase
Eccentricphase
abduction
Scapularelevation
Increased UT activity 1,43%Increased SA activity 2,37%
Forward flexionPAIN DOES CHANGE SCAPULAR MUSCLE RECRUITMENT
Ann Cools Wrightington Nov 2012
« Take home message »� Manual stretching pect minor has positive
short term effects
� Increased ROM and symptom relief afterposterior shoulder stretching
� Adding conscious scapular correctionincreases muscle activity during exercises
� Scapular rehab program results in strength gain in scapulaand shoulder
� Take into account that pain can change muscle recruitment
37
Ann Cools Wrightington Nov 2012 38
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