The Disabled Throwing Shoulder- 2017 Update Role of the scapula - - PowerPoint PPT Presentation

The Disabled Throwing Shoulder- 2017 Update

Role of the scapula

• W. Ben Kibler, MD

Medical director

• W. Ben Kibler, MD

Shoulder Center of KY Disclosure Disorders of the Scapula and Their Role in Shoulder Injury

Scapular roles

• Mobile but stable platform for muscle

action throughout shoulder ROM

• Congruent socket for dynamic

ball/socket kinematics

• Link in kinetic chain- force transfer

(core> arm), control at joints

THE KINETIC CHAIN

Force generation Force regulation, transfer Force delivery

Scapular dyskinesis- 1

• Dyskinesis as an impairment of
• ptimal scapular/arm function
• Potential to affect scapular roles

in shoulder/arm function, SHR – Static position, dynamic motion – Muscle strength, joint mobility

Kibler et al BJSM 2013

Scapular dyskinesis- 1

• Dyskinetic shoulders- 43% increased

risk of subsequent injury – Hickey et al BJSM 2017

• Dyskinetic shoulders fail earlier under

the same exposure, load

• Evaluation in asymptomatic athletes

Dyskinesis/labral injury

• Dyskinesis- 94%- clinical labral injuries
• Risk factor in “cascade to injury”
• Protracted scapula
• Labral/rotator cuff compression- ABER
• Labral shear with arm rotation
• “Internal impingement”

Scapular dyskinesis- 2

• Associated with symptomatic

shoulders

• 67- 100%, all pathology
• ? Cause, effect- part of altered

anatomy, physiology, mechanics

• Evaluate, treat as needed

Dr S Yoo Biceps/labral complex pressure

158MPa 30MPa

5 degree anterior scapular tilt

Scapula Orientation

Upward rotation Internal rotation Anterior tilt 30º 30º 10º 40º 20º 40º 20º 0º T Mihata

Decreased upward rotation Increased internal rotation

What affects internal impingement?

Increased area Increased area and pressure Internal impingement Internal impingement T Mihata

Scapular External Rotation

Humeral Elevation (degrees) External Rotation Non-Injured Injured

Scapular Upward Rotation

Upward Rotation Humeral Elevation (degrees) Non-Injured Injured

Dyskinesis/labral injury

• Clinical prediction process
• Proven labral injury
• Predictors for failure of PT,

need for surgery – Painful arc, protracted scapula

Kibler, Arthroscopy 2013

SCAPULAR EXAM

• Establish presence/absence of

dyskinesis

• Effects of corrective maneuvers
• Assess causative factors

Clinical observation

• Position – medial border
• Motion – dyskinesis

patterns: I (inferior medial), II (medial), III (superior medial) – yes/no

• 3-5 reps, flexion, 3-5 lb wt

“Yes/No”

• “Yes”/“No” seen/not seen
• Specificity-.64,sensitivity-

.82/(+),PV-.84- bone

• Clinically useful, similar to
• ther shoulder exam tests
• Uhl et al Arthroscopy 25(11): 1240-1248,

2009

EVALUATION

• Corrective maneuvers

– Scapular Assistance Test (SAT)

• Assist scap upward

rotation/posterior tilt

• (+)- Relief of external

impingement sx – Kibler et al AJSM,1998 – Rabin et al, JOSPT, 2006

EVALUATION

• Corrective maneuvers

– Scapular Retraction Test (SRT)

• Assist scapular external

rotation/posterior tilt

• (+)- Inc rot cuff strength,

relief-int impingement – Kibler et al AJSM 1998 – Kibler et al AJSM, 2006

EVALUATION

• Checklist of causative factors
• Bony- fx, separation
• Joint- labral, rot cuff, biceps
• Muscular- weakness, inhibition,

imbalance, injury

• Neurological

Dyskinesis- nonoperative

Lower trap weakness, inhibition Upper trap tightness, weakness Pect Minor tightness Altered GH rotation- IR, ER Lat dorsi tightness Serratus anterior weakness, inhibition Core weakness, dec facilitation Arthritis

Dyskinesis- operative

Scapular muscle detachment Long thoracic, accessory nerve injury Pect Minor tightness Fx clavicle, AC joint injury GH joint injury- labral, biceps, rotator cuff, arthritis Snapping scapula

Conclusions

• Scapula position/motion key to

shoulder function/injury

• Dyskinesis- affects symptoms
• Evaluation for dyskinesis in all

shoulder injuries

• Scapular restoration as part of shoulder

treatment

Considerations in rehabilitation of scapular dyskinesis

Scapula factors

• Scapular dyskinesis
• Loss of dynamic scapular

retraction control

• Multiple factors
• Commonly- “lower trapezius

deficiency syndrome”

Scapula factors

• Lower trapezius “turned off”
• Dec low trap activation

– Inc up trap activation – Inc latissimus activation – Tightness- ant muscles- pect minor, biceps, neck

Scapula factors

• Turn on low trap activation
• No inc up trap activation
• Stay below impingement
• Include kinetic chain

activation to maximize scapular muscle activation

Scapular rehab

• Muscle activations

– Serratus- ext rotation – Low trap- stabilizer in retraction – Rhomboids- stabilizers – Up trap- minimal early

Scapular retraction

• Scapular stability series

– Low row, lawnmower, robbery, fencing, glide – Early in sequence – Low loads – Arm below impingement

Isometric Exercises

Inferior Glide Low Row

Dynamic Exercises

Lawnmower Robbery

Kibler, WB; Sciascia, AD; Uhl, TL et al, AJSM 39(6): 1789-1798, 2008

Ellenbecker and Cools BJSM

References

• Burkhart S et al. The disabled throwing shoulder,

spectrum of pathology, Arthroscopy 2003

• Kibler et al. The DTS, 10 year update.

Arthroscopy 2013

• Thomas S et al. The scapula and the throwing/
• verhead athlete, in Disorders of the scapula

and their role in shoulder injury, Springer 2017

THANK YOU

www.shouldercenterofky.com