Scapular function and dysfunction

- Impingement- Muscle detachment

W. Ben Kibler, MD

Medical director

FUNCTION

IMPINGEMENT REVISITED

• Is “impingement” always a diagnosis- isolated description of pathology to base treatment upon- or more likely a syndrome-multiple causative factors

WHAT IS IT• Dr Charles Neer- JBJS 1972• Rotator cuff under acromion,

coraco-acromial arch• Subacromial alteration• Abrasive wear- stages 1,2,3• Anterior acromioplasty

EVALUATION• Exam-find the impingement

positions- painful arc– Neer, Hawkins maneuvers

• Test- eliminate sx- injection• X-ray- anatomy- outlet view• “Diagnosis”- impingement

TREATMENT• Follows exam and tests that

make the “diagnosis”• Numb up the space• Address acromion/C-A arch-

increase subacromial space• “Raise the roof”• Open vs arthroscopic

TREATMENT• Non operative

– Modalities– Rotator cuff based exercises to address demonstrated weakness

– Mobilization- stiffness

TREATMENT• Operative

– SAD, +/- DCE– Another DCE– Other scope- labral, capsular release

• Pain clinic

OUTCOMES• Very variable• Generally good- early

symptom relief• Later failures- return of sx• Not as good for young

throwers, workers- 47--77%

OUTCOMES• JBJS(Br)- 2009

– Outcomes from surgery or rehabilitation are the same

– More cost for surgery– “Natural history not well understood”

IMPINGEMENT • Frequently is an alteration

of normal coupled scapulohumeral rhythm, creating pressure/tension in a confined changeable space with many pain receptors

IMPINGEMENT• Broader perspective- factors

causative for “impingement”• Dx “impingement”- start of

the process, not the end• Appropriate treatment based

on all factors in diagnosis

Scapula/impingement• BJSM 2013 Scapular Summit• “Substantial frequent

involvement in symptoms”• ? Cause or effect• Altered acromion, sub

acromial space, strength

IMPINGEMENT • 3-D kinematic

analysis–Decreased

posterior tilting significantly (~10°)

– Lukasiewicz et al. JOSPT 1999

– Ludewig & Cook PT 2000

DYSFUNCTION

DYSFUNCTION

EVALUATION• Scapular exam

– Clinical observation– Position– Motion- arm motion– Corrective maneuvers

EVALUATION• Corrective

maneuvers– Scapular

Assistance Test

• Assist scapular upward rotation/posterior tilt

• (+)- Relief of external impingement symptoms

– Kibler,W.B. AJSM 26(2):325-337, 1998

– Rabin, A. et al, JOSPT 36(9): 653-660, 2006

SAT Results: Posterior Tilt

-20

-15

-10

-5

0

5

10

15

20

30 60 90 120

Post

erio

r Tilt

(Deg

rees

)

Unassisted SAT

Main Effect:SAT (5°) > Unassisted (-2°)p =.007

EVALUATION• Corrective

maneuvers– Scapular

Retraction Test

• Assist scapular external rotation/posterior tilt

• (+)- Inc rot cuff strength, relief- internal impingement

– Kibler WB, AJSM 1998– Kibler WB, Sciascia AD, Dome

DC, American Journal of Sports Medicine, 34(10): 1643-1647, 2006

Muscle detachment• Scapular emphasis• MD- previous surgery inc sx• “I know something’s not

attached- find out what”• Surgical exploration- tear• ? How to fix

Muscle detachment• More cases over years• How to clinically categorize

the symptoms, clinical picture, treatment

• Surgical treatments• What are the outcomes

Clinical Results from Kibler et al JSES 2014

Prospective studyInjury mechanism Number (%)MVA 35 (45)Traction/load 19 (24)Athletics 15 (19)Other 9 (12)

Prospective study• Patient reported complaints

– Localized medial border scapular pain- 78 (100%)

– Decreased overhead activity capability- 77 (99)

– Decreased forward flexion capability- 76 (97)

Prospective study• Patient reported complaints

– Headaches/muscle spasms- 67 (86)

– Decreased flexion strength- 52 (67)

– Decreased abduction/over head strength- 46 (59)

Prospective study• Sx duration 51(1.5- 372) mos• 4 (1- 20) other physicians• 1 (0-6) other surgeries• PT 14 (1- 42) mos• 3 (2 CT, 1 MRI) imaging

positive for muscular injury

Prospective study• Physical exam findings

– Dyskinesis- 78 (100)– Medial border pain- 76 (97)– (+) SRT- 76 (97)– (+) SAT- 76 (97)

Prospective study • Physical exam findings

– Can’t raise > 90- 75 (96)– Weak rotator cuff- 59 (76)– Palpable defect- 47 (60)– (+) impingement- 40 (51)

Prospective study• Surgical findings

– Low trap- 78 (100)– Rhomboids- 78 (100)– Increased scar- 16 (20)– Serratus- 4 (5)

Foot Head

Medial Scapular Border

Infraspinatus MuscleScapular Spine

Lower Trapezius

Muscle

Detachment

Prospective studyASES scores (N= 78)

Intake/DischargePain 18/35 P<.0001Function 20/28 P<.0001Total 38/63 P<.0001

Prospective study2- 3 year ASES scores (N=34)

Intake/Discharge/Follow upPain 20/34/35 P<.0001Function 19/30/34 P<.0001Total 39/63/69 P<.0001

Conclusions• Specific clinical syndrome• Major activity/life disruption• Consistent history, physical

exam, sx, dysfunction• Imaging not helpful• Consistent surgical findings

Conclusions• More awareness• Need to recognize the acute

injury and start definitive treatment so that the long term problems don’t get established

THANK YOU