Progressive Therapeutic Exercise Strategies for Shoulder Dyskinesis

Scapulothoracic Joint

• Resting position

• 17 muscle attachments

• Force couples of the shoulder

• Normal vs abnormal Scapulohumeral rhythm

Scapular Resting Position

Clinical Importance of Multiple Muscle Attachments

• 17 muscles

• Stabilize

• Move

Scapulohumeral Rhythm

• Setting Phase

• Preserves length-tension relationship of GH muscles

• Prevents impingement between humerus and acromion

Force Couples of Shoulder

Why is Scapular Function Important

• Scapular upward rotation and axial rotation was impaired in subjects with chronic impingement syndrome. Endo K, et al. J Orthop Sci 2001

• Serrated dysfunction evidenced by decreased upward rotation and increased anterior tipping and winging in patients with impingement syndrome. Ludwig et al. Phys Ther 2000

• Rehabilitation of shoulder impingement syndrome and rotator cuff injuries: an evidence-based review Ellenbecker et al. Br J Sports Med 2010

What is Scapula Dyskinesis

• Altered scapulohumeral rhythm

• Decreased scapular upward rotation, posterior tilt, and lateral rotation

• Can cause shoulder impingement, instability, neck pain

Causes of Scapular Dysfunction

• Nerve impingement

• Lack of Soft tissue flexibility

• Abnormal scapular position

• Dysfunctional movement patterns

• Poor strength and motor control

Clinical Manifestation of Scapular Dyskinesis

• Kibler, et al 2002

• Type I - increased anterior tilting

• Prominent inferior angle

Clinical Manifestation of Scapular Dyskinesis

• Type II - Prominence of entire medial scapular border

• Common in patients with glenohumeral instability

Key Components of Therapeutic Interventions for Scapular Dyskinesis

• Alignment

• Soft tissue restrictions

• Altered Scapular movement patterns

• Strength and Motor Control

• Kinetic Chain

• Cools, et al 2013

Soft Tissue Restrictions

• Short pectoralis minor

• Posterior GH tightness

• Latissimus dorsi

Pectoralis Minor Stretching

Posterior Capsule Stretching

Altered Muscle Performance

• Lack of co-contraction and force couple activity

• Strength deficits

Emphasize Dynamic and Neuromuscular Control

• Efficient dynamic stabilization and neuromuscular control of glenohumeral joint is necessary to avoid injury

• Scapular strength and stability are essential for proper function of the glenohumeral joint

• Rhythmic stabilization

• Reactive neuromuscular control drills

• Closed kinetic chain drills

• Plyometric exercises

• Reinold,et al 2010

Conscious Muscle Control• Improve proprioception and

normalize scapular resting position

• Mottram, et al 2009 found that it is possible to teach a normal subject to consistently reproduce movements of the scapula into a posterior tilt and upward rotation.

• Corrective exercises should be performed prior to dynamic movements

Dynamic Motor Control• Continue to challenge

dynamic stabilization/neuromuscular control

• Open vs closed chain activities

• Hardwick, et al 2006 demonstrated that wall slide exercise produces similar SA activity as wall push up with plus

Quadruped rock-back

Strength Training• Focus on strengthening weak

scapular muscles without increasing activity of hyperactive muscles

• Low UT/LT, UT/MT, and UT/SA ratios

• Goal to strengthen SA and LT

• Reinold, et al 2009

Best Strengthening Exercise for Serratus Anterior

• Push up with plus on physioball

• Dynamic hug

• Serratus punch at 120 degrees

Best Strengthening Exercise for the LT

• Prone full can

• Prone ER at 90 degrees Abduction

• Prone Horizontal Abduction at 90 degrees ER

Best Strengthening Exercise for Suprapinatus

• Full can with scapular retraction below 60 degrees

• Prone full can

Best Strengthening Exercise for Infraspinatus/Teres Minor

• Side lying ER with towel

• Prone ER at 90 degrees Abduction

• Standing ER at 45 degrees scapular Abduction

Best Strengthening Exercises for Subscapularis

• IR at 0 degrees Abduction

• IR at 90 degrees of Abduction

• Push up with plus on ball

• Dynamic hug

Integration of Kinetic Chain

• Implement sport-specific activities

• Perform plyometric and eccentric exercises

• Core/Proximal hip strengthening

Do's and Dont's• Avoid anterior humeral glide

• Avoid over stretching anterior capsule in swimmers and throwers

• Postural alignment

• Be careful with prone ball exercises

• "Down and back"

Other Things to Consider

• Breathing Patterns

• Pelvic position

• Taping/postural shirts

• NMES

Conclusion• Many factors contributing to

altered scapular kinematics

• Need to have good understanding of scapulohumeral rhythm

• Select most appropriate exercise

• Integrate Kinetic Chain

Thank you