SHOULDER PAIN: SCAPULAR VS GLENOHUMERAL DYSFUNCTION:

WHICH IS THE CHICKEN & WHICH IS THE EGG?

TANYA BELL-JENJE (MSC, PHYSIO)

PLAN OF ATTACK

• Sources of RCRSP

• Scapula Neutral – optimal position & relevance

• Normal scapula-humeral rhythm

• Scapula Dyskinesis – reliability

• Postural influences on scap position

• Glenohumeral neutral

• TAM, TAMD & GIRD

• Give & Restriction

• When is scapular dyskinesis causative (the chicken)

• When is scapular dyskinesis compensatory (the egg)

• Proposed management 2

WHEN WE ARE PRESENTED WITH A PATIENT WITH SHOULDER DYSFUNCTION – HOW DO WE DECIDE / CLINICALLY REASON WHERE TO START?WHAT IS THE PRIMARY SOURCE / DRIVER/ ‘MALDITA’?

Area

A: Glenohumeral

B: Scapula

C: Cervical

D: Thoracic

E: Postural

F: Cognitive/ psychosocial

G: Kinetic chain

Structure

Articular

Muscle

Tendon

Ligamentous

Capsule

Myofascial

Neural

Vascular

Bursal

Primary dysfunction

Non-optimal alignment

Muscle imbalances

Motor control /

timing/ sequencing

Instability

Overload

Underload

CAUSES OF ROTATOR CUFF RELATED SHOULDER PAIN (RCRSP)

• Anatomical narrowing of subacromial space • Humeral head translates anteriorly or superiorly

• RCT, LHB tear, failure coronal FC, overactive UFT, tight post structures

• Scapular malposition

• Elevation, downward rotation, anterior tilt

• Degeneration AC joint &/or thickening of CAL

• Postural dysfunction

• Thoracic kyphosis, FHP

• Space occupying structure reduce available volume in SAS• Swollen tendon

• Bursitis (there are 8-12 bursa in shoulder)

• SOME OR ALL OF THE ABOVE

(Holmgren, 2014; Lewis et al, 2005; McCreesh & Lewis, 2013; Wilk et al, 2009), Salamh & Lewis, 2020)

LET'S START WITH SCAPULA ARTHROKINEMATICS

SCAPULA OVERVIEW: NEUTRAL POSITION

▪ Slight upward rotation

▪ Inferior angle more lateral than root

▪ Flat against chest wall

▪ Good balanced muscle tone

SCAPULAR POSITION

• Historically assessed at rest

• Optimal scapula position allows optimal balance between all muscles that attach to the scapula

• Static scapular measure have no correlation to shoulder injuries

• ‘If it ain’t right at rest, it ain’t gonna be right during motion’ 7

THE SCAPULAR IS A SESAMOIDBONE

• It functions as a hub –distributing & sharing forces between synergistic & antagonistic muscles (Gupta

& Van der Helm, 2004)

• Tensegrity structures show resiliency, getting more stiff & rigid the more they are loaded

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SCAPULAR DYSFUNCTION:ADDUCTION, DOWNWARD ROTATION, ELEVATION, WINGING,

INTERNAL ROTATION, ANTERIOR TILT. ANY COMBINATION OF ABOVE

SCAPULAR DYSFUNCTION:ADDUCTION, DOWNWARD ROTATION, ELEVATION, WINGING,

INTERNAL ROTATION, ANTERIOR TILT. ANY COMBINATION OF ABOVE

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OPTIMAL SCAPULA MOTION DURING SHOULDER ELEVATION

NORMAL SCAPULAR MOTION DURING SHOULDER ELEVATION

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• Serratus anterior & lower traps

• For centring of the glenoid with the head of humerus

• To clear the acromion from elevating greater tuberosity

During GH abduction: Upward rotation

• Lower traps & optimal extensibility pec minor

• To clear the corocoid from elevating lessor tuberosity

During GH flexion: posterior tilt

• Elevation, retraction & backward rotation at the AC & SC joints

Clavicular motion (Ludewig, 2009)

QUESTIONS/ PROBLEMS

▪ When is scapular dysfunction causative & when is it compensatory in shoulder pain?

▪ Is it a problem when we see scapular dysfunction or is it a normal variation?

▪ Is scapular dyskinesis diagnostic of different shoulder pathologies?

▪ Are our testing procedures reliable?

QUESTIONS/ PROBLEMS

▪ When is scapular dysfunction causative & when is it compensatory in shoulder pain?

▪ Is it a problem when we see scapular dysfunction or is it a normal variation?

▪ Is scapular dyskinesis diagnostic of different shoulder pathologies?

▪ Are our testing procedures reliable?

CONFOUNDING RESEARCH

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Poor Quality trials

Methodological weaknesses

Small sample sizes

Disparity in terminology. Scapular movements are not reliably described the

same way

Shoulder diagnosis often questionable

Studies have diametrically opposite findings

On review, most testing procedures poor reliability. No optimal cluster of tests that correlate symptoms,

disability or outcome

There is a large variation of scapulo-humeral rhythm

between & within subjects, at different speeds & loads

(Blanch, 2004).

61% of overhead athletes have scapular dyskinesis

compared to non overhead athletes – so is this a normal

finding? (Burn et al, 2016)

Poor intertester reliability amongst experienced

physio’s when analysing scapular dyskinesis (Hickey

et al, 2006).

IS THERE A RELATIONSHIP BETWEEN SCAPULAR ORIENTATION & SUBACROMIAL IMPINGEMENT SYNDROME?: META-ANALYSIS. 7445 ABSTRACTS. ONLY 10 OF ADEQUATE QUALITY TO BE ANALYSED (0.13%!) (RATCLIFFE ET AL, 2014)

• Findings inconsistent: Diametrically opposite findings eg upward vs downward rotation; posterior vs anterior tilt (Ludewig, Reynolds, 2009)

• There is currently insufficient evidence that scapular postural or positional change with SIS is consistent or even part of aetiology.

EFFECTIVENESS OF SCAPULA-FOCUSED APPROACH IN PATIENTS WITH ROTATOR CUFF RELATED SHOULDER PAIN: SYSTEMATIC REVIEW (BURY ET AL, 2016)

Only 4 out of 437 studies met the inclusion criteria (0.9%!)

Benefit up to 6 weeks, but this benefit not apparent at 6 months.

Early changes in pain are not significant

Effect of Scapular focused rehab approach is unclear & current evidence conflicting

2017

• 795 Studies: Only 4 met inclusion criteria (0.5%!)

• Altered scapular positioning may be a risk factor in the development of SPS

• No evidence that changes in scapular strength can be associated with changes in subacromial pain syndrome

• Unclear what effects a scapular focused treatment approach have on shoulder pain or function

• Not known what exercises would be best

• No evidence to support the use of taping

VALUE OF ASSESSING SCAPULAR POSITION (?)

• Clinicians knowledge of shoulder pain seems to increase bias towards reporting scapular dyskinesis (Plummer et al, 2017).

• Dynamic scapula evaluation is neither reliable nor accurate & cannot be used to identify a pathologic shoulder (Kuhn, 2009).

• Overall, no physical examination test of the scapula was found to be useful in differentially diagnosing pathologies of the shoulder (Wright et al, 2013)

SCAPULAR DYSKINESIS REPORTED IN VARIOUS UPPER QUARTER PAIN PRESENTATIONS

• Mechanical neck pain

• Rotator Cuff Tear (may behave differently depending on size of tear)

• Type of impingement

• Subacromial

• Internal / posterior

• Adhesive Capsulitis / Stiff shoulder

• Shoulder instability

• Pain inhibition

• Postural influences / positional change

• Fatigue

• Fear Avoidance

Kibler et al, 2013; Cools et al, 2014; Falla et al 2007; Cagnie et al, 2014; Kibler 2003

INSTABILITY

Several studies have found that surgical correction of multidirectional instabilities or of RCT’s has been found to correct the scapular compensation (Ludewig,

Reynolds,2009)

Scapular Dyskinesis

Neck / Shoulder

Pain

Pain inhibition

AXIOSCAPULAR MUSCLE LINKAGE

It is clinically recognised that patients with mechanical neck pain have similar changes in scapular position & dyskinesis as patients with painful shoulders (Cools et al, 2014)

• Aggressive strengthening in presence of scapular dyskinesis will only reinforce poor kinematics & not provide relief in pain or improvement in function (Lewis,2009 Cools et

al, 2014)

POOR CERVICO-THORACIC & LUMBAR POSTURES INFLUENCE SHOULDER

ROM & SCAPULAR POSITION

• FHPThoracic kyphosisScoliosisFlat / inverted thoracic spine

• Can cause:• Shoulder impingement

syndromes

• Altered neurodynamics

• Muscle imbalances

• Joint incongruity

• Ligament laxity

▪ A ‘slouched ‘posture = thoracic kyphosis

▪ Anteriorly translated GH joint▪ ↓ Scap Upward Rotation▪ ↑ Scap Ant tilt▪ ↑ Scap protraction▪ ↑Scap elevation (Wang, 2012)

• Loss of GH elevation & abduction (Kebaetse,

1999; Bullock et al, 2005)

• Altered length-tension of shoulder-girdle muscles (Grimsby & Gray, 1997)

• Mal-tracking of humeral head in glenoid (Wilk & Arrigo, 1993)

• subacromial space resulting in various impingement type conditions (Gumina et al,

2008)

Postural effects

TESTING: THE SCAPULAR ASSISTANCE TEST (SEITZ ET AL, 2012)

• Assisting upward rotation / posterior tilt eases symptoms

• Increases the size of the subacromial space

• May indicate that scapular strengthening to reposition might help, but NOT definitive

• REMEMBER that the SAT also offloads the shoulder, so perhaps just alleviating pressure off swollen tendon?

• OR perhaps just offloading an overloaded upper quarter

• If the SAT eases, then there is more chance of a better outcome – some predictive value

An ‘Improvement’ Test

SUMMARY -SCAPULAR DYSFUNCTION

▪ Most dysfunctions are:

↓in upward rotation &/or ↓posterior tilt

↑ in scapular elevation

▪ Provocative in reducing subacromial space.

▪ Change arthrokinematics of the glenoid via scapular malposition

can cause RCRSP (Ludewig & Cook, 2000, Endo et al, 2004, Lukasiewicz et al,

1999).

• Conflicting & Limited evidence to support assessment or primary

treatment of scapular dyskinesis in treatment of RCRSP

• Scapular Kinematics & its relationship with shoulder pain is not

well supported.

• Scapular Dyskinesis may be a normal variant

NOW LOOKING AT GH FUNCTION, OPTIMAL POSITIONING &

DYSFUNCTION

NEUTRAL ZONE OF THE GH JOINT: CENTRING HEAD IN GLENOID

Maintain optimal acromio-humeral

Space

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• Normal Acromio-humeral distance (AHD) = up to 12mm (Wang

et al, 2005)

• Deficiencies in Coronal FC can cause 8mm superior translation (Thompson et al, 1996) & a 61% increase in compression of acromion onto supraspinatus tendon (Wuelker et al, 1994)

• Correlation between tight posterior structures & decreased AHD (Maenhout et al, 2012; Mackenzie, 2014).

• More than 20° IR difference side to side (Burkhart et al,2003, Kibler et al, 2012)

• Antero-superior translation of the humeral head during GH flexion

• Postero-superior translation during Abd/ER

Tight / stiff post structures cause a GIRD and a shift in the GH rotation forces

TOTAL ARC OF MOTION (TAM)

• Where the sum of glenohumeral Internal AND External rotation is equal (within 10%) of the unaffected side (Kibler, 2012)

• In throwers, can see a rotational shift: ↓ in GIR & relative ↑ in GER so that the total arc of motion (TAM) should remain bilaterally equal (Kibler et al, 2012).

• Adaptation may be attributed to humeral retroversion (little leaguers) (Kelsey et al, 2016).

• Greater retroversion in adulthood (70° vs 30°) not clinically modifiable.

KEY FACTOR IN GH ARTHROKINEMATICS IS OPTIMAL GH INTERNAL & EXTERNAL ROTATION(KIBLER ET AL, 2012)

• To maximise performance & minimise injury risk

• Allows head to be centred in glenoid

• Maximises cavity compression

• Optimal ER contributes to maximal hand & ball velocity

• Optimal ER ↓’s valgus loads at elbow

TOTAL ARC OF MOTION DEFICIT (TAMD) WILK ET AL, 2002

• More than 10% of the total rotation (sum of IR + ER) lost compared to the unaffected shoulder

TAMD: CAUSES• LOSS OF GH INTERNAL ROTATION (GIRD):

• Restrictions in Posterior Capsule, Infraspinatus / Teres Minor

• Head not centred: antero-superior early impingement

• LOSS OF GH EXTERNAL ROTATION• Restriction of clavicular backward rotation

• Inextensible Lat Dorsi & / or Pec major

• Swollen rotator cuff or biceps tendon

• Head not centred: postero-superior early impingement

NOW WE NEED TO DEFINE & UNDERSTAND THE CONCEPT OF GIVE & RESTRICTION

(RELATIVE FLEXIBILITY ) SAHRMANN

RELATIVE FLEXIBILITY (SAHRMANN, 2002)

▪ When there is a breakdown in 1 link in the kinetic chain (restriction) the gross body movement will only be slightly affected due to excessive compensatory movt (give) that occurs at other components of the Kinetic chain.

▪ The Body takes the path of least resistance

BIOMECHANICAL FUNCTION

A HEALTHY UPPER QUARTER REQUIRES SYNCHRONOUS DISTRIBUTION OF

NORMAL MOBILITY

The site of the restriction is the ‘source’ of the problem, the site of the ‘give’ is usually the site of the pain

Treat the Restriction to clear the Give

RESTRICTION: GH LATERAL ROTATIONGIVE: GH SUP TRANSLATION &/OR SCAPULAR ADDUCTION / DOWNWARD ROTATION

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RESTRICTION: GH LATERAL ROTATION

GIVE: SCAPULAR ADDUCTION (VIENNA

SAUSAGE)

RESTRICTION: GH INTERNAL ROTATIONGIVE: SCAPULAR ANTERIOR TILT (BORICH ET AL, 2006)

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▪ RESTRICTION: Glenohumeral Medial Rotation

▪ GIVE:Scapular protraction & downward rotation.Anterior translation of humeral head.

▪ Thrower presents with anterior shoulder pain.

Tight post structures, limiting internal rotation ROM in a thrower (GIRD)

(Kelsey et al, 2016)

WHAT IS THE RESTRICTION & WHAT IS THE GIVE?WHERE IS SITE OF PAIN?

WHEN IS SCAPULAR DYSKINESIS PRIMARY / CAUSATIVE?

▪ Loss of scapular upward rotation causes compensatory GH inferior translation (swimmers, rockclimbers) (Itoi et al, 1992)

▪ Hypermobility syndrome

▪ Long Thoracic, Spinal Accessory or Suprascapular nerve palsy

SO WHEN IS SCAPULAR DYSKINESIS SECONDARY/ COMPENSATORY?

▪ As a compensation for loss of Glenohumeral ROM (Med Rot, Lat Rot)

• In the presence of shoulder pain (Kibler &

McMullen, 2003) or fatigue

▪ In the presence of Shoulder instability

▪ In the presence of a Rotator cuff tear

▪ As compensation for a Stiff shoulder

▪ Secondary to cervical pain

▪ When the patient is fearful to move

▪ People in pain move differently

IF THERE IS A TAMD: 1ST

RESTORE GH ROTATION ROM:

-HOME STRETCHING PROGRAM

SCAPULAR REHAB THAT DOES NOT REQUIRE GHROTATION – EG 4-POINT

KNEELING, CLOSED CHAIN

INSTITUTE FULL SCAPULAR REHAB ONCE YOU HAVE

80+ % OF TOTAL GH ROTATION ROM

AVOID PAIN AVOID FATIGUE

ADDRESS ASSOCIATED FACTORS:

BIOPSYCHO- SOCIAL ISSUESPOSTURAL DYSFUNCTION

CO-MORBIDITIES

MANAGEMENT

LAST FEW PEARLS

• A loss of ROM at the shoulder forces a give at the scapula in an individual involved in overhead rotational activities

• Strengthening of the Shoulder External rotators cannot be achieved unless you have External Rotation ROM

• As the Scapula & the rotator cuff work together, most goodexercises will benefit both, once you have optimal arthrokinematics.

THANK YOU FOR YOUR ATTENTION!