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Thescapula:itsplaceinclinicalreasoninginpa2entswithshoulderpain
FilipStruyf,PhD,PT
Scapularassessmentanditsplaceinclinicalreasoninginpa2entswithshoulderpain
Whyshouldweadressthescapular?Howcanweassessscapularmovement?Whenshouldweassessscapularmovement?Howdoesthisfitwithinclinicalreasoning?
Whydidhomininsevolvetheabilitytothrowathighspeed?+/2millionyearsagoinHomoerectus:adapta2onsinfeaturesthatenableenergystorageandreleaseattheshoulder?Hun2ngac2vi2esintensifiedaroundthis2meEvolu2onofthehumanshoulderisthereasonwhyhumankindsurvivedOrisitthebrain?
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Abriefintroduc2on...
Proper2esofanoutcomemeasure Consensusonterminology
Proper2esofaoutcomemeasures
Reliable,valid&responsiveSomesay…
(Ludewig et al., 2009)
Whatisscapulardyskinesis?
“Thescapulademonstratesprematureorexcessiveeleva2onorprotrac2on,nonsmoothorstuPeringmo2onduringarmeleva2onorlowering,orrapiddownwardrota2onduringarmlowering”(Dysrhythmia)
“Themedialborderand/orinferiorangleofthescapulaareposteriorlydisplacedawayfromtheposteriorthorax.”(Winging)
(McClure et al. 2009)
Scapularassessmentanditsplaceinclinicalreasoninginpa2entswithshoulderpain
Whyshouldweadressthescapula?Howcanweassessscapularmovement?Whenshouldweassessscapularmovement?Howdoesthisfitwithinclinicalreasoning?
Isscapulardyskinesisthecauseoreffectofshoulderdisorders?
CAUSE?
Does scapular positioning predict shoulder pain? (Struyf et al. IJSM 2013)
Obvious scapular dyskinesis => higher probability of shoulder porblems in elite handball players (Clarsen et al. BJSM 2014)
Isscapulardyskinesisthecauseoreffectofshoulderdisorders?
EFFECT?
Hodges et al. 2013; Hodges and Tucker 2011a; Nijs et al. 2012b; Farina et al. 2001; La Pera 2001; Valeriani et al. 1999
pain-dependentinhibitoryinput(bothipsilateralandcontralateral)
Isscapulardyskinesisthecauseoreffectofshoulderdisorders?
CAUSE? EFFECT?
Assessment&Therapy
Riskoftransi2ontochronic?
Assessment&Therapy
YES
NO
“scapularmusclerehabilita2onimprovespainandfunc2on(SPADI)inpa2entswithmildimpingementsymptoms”(6weekstraining)”DeMeyetal.AmJSportsMed2012
“Alargeclinicallyimportanttreatmenteffectinfavorofscapularmotorcontroltrainingwasfoundinself-reporteddisability”Struyfetal.ClinRheum2013
Studiesthatdifferen2atehavelargersuccesrates!
6studiesincluded(>6/10PEDROscore)scapular-focusedexercisetherapyscapularmobiliza2onscapulartaping
Clinicaloutcomesofascapular-focusedtreatmentinpar2cipantswithshoulderinjury:asystema2creview(BJSMinreview)EljaAEReijneveld1,SuzieNoten2,LoriAMichener3,AnnCools4,FilipStruyf2
Moderateevidence=scapular-focusedtreatmentcomparedtootherphysiotherapeu2ctreatmentiseffec2vetoimprovescapularmusclestrengthinpar2cipantswithsubacromialimpingementsyndrome.
Conflic2ngevidencewasfoundforimprovementsinpain,func2onandclinicalmeasuresofscapularposi2oning.
Noevidencewasfoundforimprovementsinshoulderrangeofmo2on,rotatorcuffmusclestrengthandqualityoflife.
RESULTS?
Scapularassessmentanditsplaceinclinicalreasoninginpa2entswithshoulderpain
Whyshouldweassessscapularmovement?Howcanweassessscapularmovement?Whenshouldweassessscapularmovement?Howdoesthisfitwithinclinicalreasoning?
Howcanweassessscapularmovement?
Factorsthatinfluencescapularposi2oning
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VisualobservaFonofscapularposiFoning
McClure et al., 2009; Tate et al. 2009; Struyf, et al., 2009; Huang et al. 2015
a)NormalmoFon:noevidenceofabnormalityb)Subtleabnormality:mildorques2onableevidenceofabnormality,notconsistentlypresent
c)Obviousabnormality:striking,clearlyapparentabnormality,evidentonatleast3/5trials
Ra2ngscaleofMclureetal.JAT2009
Loadingdependsonbodyweight:<68kg=>1.4kgload>68kg=>2.3kg
Tate et al. 2009
Shoulderprotrac2on(Baylorsquare/acromion-tabledistance)
Pectoralisminormusclelength Scapularupwardrota2on Scapularasymmetry
Clinicalmeasurements
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Acromion–tabledistance
(Acromion-table distance (cm)/ BL (cm))*100 Reliable ! (ICC’s > 0.88)
(Nijs et al., 2005; Struyf et al. 2009)
Baylorsquaremethod Proc.spinosaC7=>Anteriorcorneracromion Reliable&valid(Petersonetal.,1997)
AlternaFvemethodinstanding?
Pectoralisminormusclelength
Inferomedialaspectofproc.corracoidèinferolateralaspectofcostosternaljunc2onofthe4thrib
Struyf et al., 2014
Pectoralisminorindex
PMI=
PectoralisMinorlength(cm)/BL(cm))x100
Reliable(intrarater)Valid?(Yestocadavericstudies)Caliper!!
26Struyf et al., 2014
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ScapularupwardrotaFon
Gravity or digital inclinometers At rest, 45°, 90°, 135° & endrange Reliable (intra) Valid (digital)
(Watson et al., 2005; Johnson et al. 2001)
Scapularasymmetry
Distance medial border scapula => proc. Spin. Th4 or Th3 Reliable & Valid
(Peterson et al. 1997, Nijs et al. 2005)
“scapulardistance” DistanceangulusacromialistoTh3 Dividedbythelengthofthespinascapulae Reliable
Scapularasymmetry
Scapularasymmetry
Lateral scapular slide test
(Koslow et al. 2003; Nijs et al. 2005)
Observa2onalevalua2onsystemsandassessmentofscapularupwardrota2onseemsuitablyevidence-basedforclinicaluse.Donotuseitasaphysicalexamina2ontestfordiagnosingpathologiesoftheshoulder.Asymmetryisok!
Insummary
Larsen et al. 2015; Wright et al. 2013; Morais et al. 2013
Whenshouldweassessscapularmovement?
IsthescapularelatedtothepaFents’shoulderpain?
IsthescapularelatedtothepaFents’shoulderpain?
ScapularAssistanceTest(SAT)ModifiedScapularAssistanceTest(mSAT)
ScapularRetrac2onTest(SRT)ScapularReposi2oningTest(SRT)
ScapularAssistanceTest
ScapularAssistanceTest(m)SAT
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reliable
(Seitz et al. 2012; Rabin et al., 2006)
ScapularreposiFoningtest
reposi2oningtest(SRT)
35
reliable Reduces pain and increase strength
(Tate et al., 2008)
Howdoesthisfitwithinclinicalreasoning?
Atthispoint…
Clinicianscanusereliable(andvalid)clinicaltestsfortheassessmentofbothsta2canddynamicscapularposi2oninginpa2entswithshoulderpain.
Nocausalassocia2onwithshoulderpainproven
Benefitofsymptomaltera2ontests
Scapulardyskinesis≠diagnosis
isaclearexampleofanassessmentstrategythatemphasizesthesearchfordysfunc2ons
Scapulardyskinesis
prognosesofshoulderpainisnega2velyalteredbymorethenmovementimpairmentorpainseverityalone.
Clinicalreasoning:factoranalysisof…PsychosocialNeurophysiological
LifestyleMovementrelatedimpairments
DONOTPATHOLOGIZEYOURPATIENTPROFILEYOURPATIENT
WhatabouttheSICKscapulasyndrome?
Scapularmalposi2onInferiormedialborderprominenceCoracoidpainKinesisabnormaili2esofthescapula
Shouldweuseanalgorithm?
easytofollow andhavetheinten2ontoeliminateunconsciousmistakes
excellentwaytostructureandvisualizeclinicalreasoningprocesses
Shouldweuseanalgorithm?
“easytofollow”=rela2velysimple Ashoulderpainpa2ents≠simple itwouldbeeasiertousereasontosolvetheproblem.
Shouldweuseanalgorithm?
Whatifthepa2ent’sshoulderproblemfallsoutsideofthereasoningofthealgorithm?
=>itwillnotbefixed
Shouldweuseanalgorithm?
Insummary
useapa2ent-centeredapproach,profilingthepa2ents’psychosocial-,neurophysiological-,andlifestylefactorsandmovementimpairmentsthatinformourclinicaldecision-making.
Stoppathologizing,startprofiling!
