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Shoulder Assessment & Shoulder Assessment & Rehabilitation with Rehabilitation with

Emphasis on Scapular Emphasis on Scapular StabilizersStabilizers

Peggy A. Houglum, PhD, ATC, PTPeggy A. Houglum, PhD, ATC, PTDuquesne UniversityDuquesne University

Pittsburgh, PAPittsburgh, PA2007 EATA Workshop

Boston, MA

Introduction• Scapular function & biomechanics

• Examination• Evidence-Based Rehabilitation Program with Progression

Scapular Function & Biomechanics

• Three axes of rotation

• 6 Muscles Provide Scapular Stabilization & Scapular Control During Shoulder Motion Neumann, 2002

Purpose of Scapula Muscles

1) Provide stable platform for shoulder

2) Move scapula for improved shoulder function & position

3) Prevent subacromial impingement via scapular movement & position in shoulder elevation

Donatelli, 2004

#1 Shoulder ProblemChanges in 3 planes of motion impingement

Pathomechanics Etiology

1.Body posture-Ziva & Bezalel, 2001; Finley & Lee, 2003; Satterwhite, 2000; Kibler, 2000; Mottram, 1997

2.Neuromuscular alterations–Ludewig & Cook, 2000; Satterwhite, 2000; Mottram, 1997; Sahrmann, 2002

3.Overuse fatigue–DePalma & Johnson, 2003; Satterwhite, 2000; Tsai et al, 2003

4.Muscle imbalances-DePalma & Johnson, 2003; Wang & Cochrane, 2001; Satterwhite, 2000; Kibler, 2000; Sahrmann, 2002

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Pathology ProgressionAbnormal scapular motion

Abnormal biomechanics of G-H joint

Muscle overuse, fatigue, & insufficiency

Altered GH relationship

Excessive demands on static stabilizers

Excessive demands on RC

Wear & TearExcessive joint shearing forces

Glenohumeral Pathologies & Shoulder Pain

Adapted from Ziva & Bezalel, 2001

1. Effects of Body Posture• Changes scapula position• Changes in scapula position & mobility contribute to: – GH instability– RC tears– Shoulder impingement

--Paletta et al, 1997; Warner et al, 1992; Matsen & Arntz, 1990; Itio et al, 1992

• Postural changes are associated with ↑d muscle length –Sahrmann, 2002

Forward Head Posture

Δ humerus to ↓ subacromial space

Posture Impact on Scapula

• Lengthening of posterior muscles

• Protraction of scapula• Tightening of anterior muscles• Anterior tilting of scapula

2. Overuse Fatigue & Its Impact on Scapula

• Reduces muscle strength and increases response time -Cools et al, 2002

• Alters mechanics-Tsai et al, 2003; DePalma & Johnson, 2003

• Reduces functional efficiency-Voight & Thompson,2000; DePalma & Johnson, 2003

• UT elevates scapula before it rotates

3. Neuromuscular Changes

• Related to:– Posture–Repetitive mechanics

– Fatigue

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Neuromuscular ChangesImpaired

Components

Impaired Movement

Functional & Restrictive Changes

Inaccurate Feedback

Sustained Posture

Repeated MotionFatigue

Altered Neuromuscular Impact on Scapula

• Altered position becomes “normal”position

• Firing sequence and timing are altered• Incorrect mechanics become more engrained

• Scapula tilts, elevates, and protracts

4. Muscle Imbalances• Changes in scapular muscles lead to loss of glenohumeral control –Kibler, 2000; Bast et al, 2000; Su et al, 2004

• Loss of proper scapula motion leads to impingement --Wang & Cochrane, 2001; DePalma & Johnson, 2003

• Scapula changes lead to glenohumeral injuries –Kibler, 2000; Bast et al, 2000; Su et al, 2004; Wang & Cochrane, 2001; DePalma & Johnson, 2003; Ludewig & Cook, 2000; Decker et al, 1999

Muscle Imbalance Impact on Scapula

• Altered firing sequence and timing• Reduced ROM• Inappropriate scapula position for GH elevation: Protracted, anteriorly tilted

Scapular Δs Affect G-H

• Ant-Post Tilting– Relative to superior border

– Occurs with ACJ– Allows full contact of scapula to thorax

• Pathomechanics– Tight pec minor Ant Tilt

Posterior

Anterior

Scapular Δs Affect G-H• Protraction

– Protraction occurs with GH elevation

– Allows full contact of scapula to thorax

– Provides additional GH elevation

• Pathomechanics– Tight pec minor + Weak

rhomboids Protracted posture– Excessive protraction narrows subacromial

space

Retraction

Protraction

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Scapular Δs Affect G-H• ↑ Rotation

– Occur with GH elevation– Allows max. contact of glenoid with humerus

– Provides additional GH elevation ROM

• Pathomechanics– Tight pec minor + Weak rhomboids <↑ rotation impingement

– Weak LT+SA <↑ rotation impingement

↓↓ RotationRotation

↑↑ RotationRotation

Scapular Δs Affect G-H• Weak scapula muscles decreased stability

• Stable scapula is necessary for stable GH joint

• Instability subacromial impingement via <post tilt & <scapular upward rotation –Finley & Lee, 2003

Need for StabilizationOPTIMAL SHOULDER FUNCTIONOPTIMAL SHOULDER FUNCTION

SCAPULAR STABILIZATIONSCAPULAR STABILIZATION

SCAPULAR SCAPULAR CONTROLCONTROL

& & MOTIONMOTION

TRUNK STABILIZATION

Pause for Thought:What is the influence of muscle performance requirements on

rehabilitation?

Muscle Activity• Serratus Anterior: constant 20-40% throughout freestyle stroke

--Pink et al, 1991

• S.A. & Lower Trap = Most susceptible to inhibition

--Glousman et al, 1988

• Serratus Anterior: delayed activity >3 times normal & bilateral in S.I.

--Wadsworth & Bullock-Saxton, 1997

• Scapular instability: – in 68% R.C.

problems--Kuhn et al, 1995

– in 100% G-H instability

--Warner et al, 1992

Examination

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Examination• Visual Inspection– Posture–Asymmetry–ROM: Concentric & Eccentric

Shoulder ScapulaC/S Ribs

Posture Observation

Posture Observation Scapula Position on Ribs

Examination:Scapular ROM

Examination: Strength•Hips & Trunk:

= 54% throw force;c 20%↓ →34% ↑R.C.vel. --Kibler, 1995

• Shoulder• Scapula

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ExaminationScapular Muscle Strength

•Serratus Anterior•Lower Trapezius•Rhomboids

Screening Tests: Scapula• Isometric Strength --Kibler, 1998

Pinch in retraction X 20sNormal = No burning

• Isotonic Strength•Wall push-ups

Normal = No change p 10 reps

Serratus Ant. Strength Test

Lower Trap Strength Test

Rhomboid Strength Test

Rehabilitation

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Rehabilitation Progression

PerformancePerformance

AgilityAgility

ProprioceptionProprioception

Strength/EnduranceStrength/Endurance

Range of Motion/FlexibilityRange of Motion/Flexibility

Initial Rehabilitation

Range of Motion/FlexibilityRange of Motion/Flexibility

Inflammation & Rehab1 2 3

• Limit Tissue Stress:– Fibrin plug is Primary Tissue Strength

• Avoid Early Exercise:– Increases Stress to Fragile Tissue

• Goals– Control Edema & Pain– Maintain C-V & Segment Function

• Treatment:– Modalities for Edema & Pain– Joint Mob: I, II for Pain

Proliferation & Rehab1 2 3

• Tissue Remains Weak but Improving with Collagen Production

• Begin ROM with Mild Strengthening (Exception: Tendon Repairs)

• Early Proprioception, Balance• Joint mobilization: I–III for Pain, ROM• Big Difference Between Early & Late

Remodeling & Rehab

• Progressive Tensile Strength Increases Allows Concomitant Increases in Applied Stresses

• Joint Mob: II – IV• Be Aware of Excessive Stress Indicators and Respond Accordingly

1 2 3

Soft Tissue Mobilization• Assess & Treat soft tissue restrictions

• Various soft tissue techniques– TP– MFR– Massage– Strain-Counterstrain

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AC Joint Mobilizations• AP glides• PA glides• Inferior glides

SC Joint Mobilizations

• AP glides• Superior glides

• Inferior glides

GH Joint Mobilization: Oscillation

GH Mob: Inferior Glides

GH Mob: Posterior Glide

GH: Anterior Glides

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Scapulothoracic MobsScapular Distractions

Scapulothoracic MobsInferior Glide

Joint Mob: Post Glide c Medial Rotation

Joint Mob: Ant Glide c Lateral Rotation

Costovertebral Mobs FlexibilityCodman’s:Passivemotiononly

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Inferior Capsule Stretch

Posterior Capsule Stretch

Superior Capsule Stretch

Med. Rot. Stretch

Active G-H ROM Strength/Proprioception Exercises

ProprioceptionProprioception

Strength/EnduranceStrength/Endurance

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Shoulder Muscles Strength & Endurance

• Scapular Muscles– Lower Trapezius– Serratus Anterior– Rhomboids & Middle Trapezius

• GH Muscles– RC– Large Movers

Evidence-Based Exercises• Lower Trapezius

– Bouhler exercises in prone –Ekstrom et al, 2003

– Prone LR in 90° abd –Ekstrom et al, 2003

– Row or Prone row –Ekstrom et al, 2003; Moseley et al, 1992

– Horizontal abduction c LR --Moseley et al, 1992; Ekstrom et al, 2003

– Push-up plus -- Moseley et al, 1992

Evidence-Based Exercises• Serratus Anterior

– Upward rotation activities –Ekstrom et al, 2003; Moseley et al, 1992

– Bilateral scapular protraction –Ekstrom et al, 2003; Moseley et al, 1992; Decker et al, 1999

• Push-up plus -Moseley et al, 1992

• Dynamic hug -Decker et al, 1999

• Simultaneous SA and UT activity– Bouhlers in prone –Ekstrom et al, 2003

– Shoulder abduction in scapular plane –Ekstrom et al, 2003

Evidence-Based Exercises

• Rhomboids and Middle Trapezius– Prone Bouhlers –Ekstrom et al, 2003

– Horizontal extension with LR –Ekstrom et al, 2003; Moseley et al, 1992

– Row –Ekstrom et al, 2003; Moseley et al, 1992

Evidence-Based Exercises• Rotator Cuff

– Supraspinatus: • Prone horizontal abduction in LR

--Blackburn et al, 1990

• Military press --Townsend et al, 1991

• Scapular plane elevation --Townsend et al, 1991

– Infraspinatus & Teres Minor:• Prone LR in 90° abduction & elbow flexion --Blackburn et al, 1990

• Lateral rotation --Townsend et al, 1991

Evidence-Based Exercises for Shoulder Movers --Townsend et al, 1991

• Deltoid– Shoulder abduction

– Shoulder flexion– Military press– Row

• Pectoralis Major– Press-up– Push-up

• Latissimus Dorsi– Press-up

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Other Evidence-Based Info

• Proprioceptors are damaged – Must be restored for function –Myers &

Lephart, 2000

• Scapular stability must be restored before scapular movement –Mottram, 1997

• Scapula setting must be established before activity –Mottram, 1997; Smith et al, 2002

Scapular Taping• For secondary impingement• Facilitates lower & middle trap and inhibits upper trap --Morin et al, 1997

• Enhances muscle re-ed & scapula positioning with ↓ pain --Host, 1995; Lewis et al, 2005

• be accompanied c exerciseMUST

Scapular Taping Early Exercises

• Open Kinetic Chain* JRS: Mimic Positions * Stabilizing Against Manual Resistance

-Sidelying with manual resistance-Supine with isometric resistance

Early HEP: Isometrics

LR

MRABD

Rotator Cuff

Early HEP: Isometrics

Flexors

Extensors

Joint Movers

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Manual ResistanceSidelying with manual resistance

Manual ResistanceSupine with isometric resistance

R. C. Resistance

Keep in Lower Ranges- Abduction to 30°- LR to 0°- MR Starts at 0°

CKC Stabilization• Static

*Quadruped with resistance*Tripod/Bipod with resistance

• Low Level Dynamic: Swiss Ball*Legs on ball & *Arms on ballIncreasingly Unstable Base*Balance board: c & s Swiss Ball*Fitter: on knees, on feet, on bench

Rhythmic Stabilization Low Level on Swiss Ball

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Quadruped Weight Bearing

Tripod Weight Bearing

Biped Weight Bearing Rhythmic Stabilization

TB: Rotator Cuff Abduction

TB: Rotator Cuff - L.R.

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TB: Rotator Cuff - M.R. TB: Serratus Anterior

TB: Lower Trapezius TB: Rhomboids

Concentric/Eccentric

• PNF & Manual Resistance– *Isometric, concentric, eccentric

• Eccentric Pushups– *Wall c & s manual resistance

– *On incline, on floor, on boxes

Push-up: Early Progression

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Push-up: Early Progression

Push-up: Early Progression

Push-up: Early Progression

Push-up: Early Progression

Other Scapular Concentric/Eccentrics

• Bouhlers: Upward Rotators• Lower Trap Strengthening• Advanced Theraband Exercises

• Seated Pushups: Shoulder girdle

Scapular Strength: Bouhlers

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Scapular Strength: Advanced Bouhlers

Scapular Strength: Lower Trap

Straight-Plane Elastic-Band Exercises

Diagonal-Plane Exercises

Diagonal-Plane Exercises

Shoulder Girdle Strength

Seated Push-up

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Medicine Ball Exercises

• Quadruped Balance Activities• Stabilization at 90º Elevation in Supine

• Seated Alphabet

Alphabet with Medicine Ball

ProgressiveMedicine Ball Exercises• Supine ER Drop Catches• Supine Toss: Progressive Throwing

• Standing Eccentric IR & ER• Rebounder Activities

Supine Eccentrics: Early

Supine Eccentrics, Early Upright Eccentric/Concentric

Tosses: IR

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Upright Eccentric/Concentric

Tosses: ERMachine Exercises

• Bench Press Plus:Controlled & Ballistic

• Lower Trap on Lat Pull down unit• Flies:

Reverse Flies & Rows• Seated Press Downs

Shoulder Girdle Strength

RowRow

Fly and Reverse Fly

Shoulder Girdle StrengthEccentric Bench Press Plus

Other Upper Quarter Considerations

• PostureLumbar PostureCervical & Thoracic Posture

• Core & Trunk StrengthTransverse abdom./MultifidusObliques & Rectus abdom/Quad Lumborum

• Hip Strength & Flexibility

Core Exercises• Early

– Hip, Trunk, & Core Strength– Lower Abdominals

• Later– Medicine Ball Sit-ups

* Chest Passes* Overhead & Rotational Passes

– Medicine Ball Twists• Advanced

– Abdominal Roller

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Core Exercises Core Exercises

Core Exercises Core Exercises

Progression of Elevation• Start Below 60o Elevation• Advance to Mid-Range Elevation• Overhead Activities Occur Last

Agility Exercises

Agility

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Use Your Imagination

Think Outside the Box!!

Agility Exercises• Isokinetics• Treadmill Walking• Wheelbarrow Exercises• Box Jumps

Moderate Agility/Coordination

Moderate Agility

Mod-Adv Agility Advanced Agility

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Advanced Agility/Core Plyometric Push-Up Variations

Plyometrics Functional & Sport Specific Activities

PerformancePerformance

Functional Activities Requirements

• Initially Controlled Conditions• Advance as Confidence Increases• Full return parameters:

•Pain Free•Full Motion•Full Strength & Endurance•Sufficient Skill Acquisition

Skill Agility Drills • Start at Short Distances• Start at Low Resistance• Start at Low Repetitions• Increase Only One Parameter at a time

• Increase Only ~ Every 3 Days

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Functional/Sport-Specific

Summary

Summary• Understand mechanism & biomechanics

• Justify all program aspects• Rehab Involves All Parameters• Core, Trunk, & Hip Exercises• Scapular Mobility, Stability, and Strength are Essential Elements

• Scapular Stabilization is Basic to Glenohumeral Function & Balance

Summary

• Scapular Control is established through logical and justifiable progression & integration of Static & Dynamic, OKC & CKC Exercises, Concentric & Eccentric, Plyometrics