Management of the Scapula in Glenohumeral Instability Steven A Stratton, PT, PhD, ATC

Steven A. Stratton, PhD, PT, ATC

• • • • •

General Physical Therapy Orthopaedic Physical Therapy Manual Therapy Spinal Rehabilitation Sports Physical Therapy

Shoulder Complex

• • • •

Sternoclavicular Joint Acromioclavicular Joint Glenohumeral Joint Scapulothoracic Joint

Shoulder Complex

Sternoclavicular Joint

Acromioclavicular Joint

Anterior Superior

Glenohumeral Joint

Shoulder Capsular-Ligamentous Complex

Scapulothoracic Joint

Scapulothoracic Joint

(Retraction) (Protraction)

Scapular Rest Position

Stability of the Shoulder Complex

•

Stability is maintained by the glenohumeral ligament complex, the compressive forces of the rotator cuff, the glenoid labrum, negative intra articular pressure, and normal kinematics of the scapula as part of scapulohumeral rhythm.

Scapulohumeral Rhythm

• •

Scapulohumeral rhythm is the coordinated interaction of the scapula with a moving humerus to keep the angle of the humerus and glenoid of the scapula within a physiological tolerable range.

Likened to a “ball on a seal’s nose”.

Rowe CR, Zarins B. Recurrent transient subluxation of the shoulder. J Bone Joint Surg Am 63: 863-872, 1981.

Scapulohumeral Rhythm

•

The coupled motion of the arm and scapula provides dynamic stability for the shoulder complex in various positions of everyday activities and athletic movements.

Glenohumeral and Scapulothoracic Contribution

• • •

Shoulder Elevation: 3 degrees of Glenohumeral (GH) joint motion for every 2 degrees of Scapulothoracic (ST) joint motion.

McQuade found up to 4.5:1 ratio under heavy shoulder loading in scapular plane of arm elevation.

McQuade KJ, Smidt GL. Dynamic scapulohumeral rhythm: the effects of external resistance during elevation of the arm in the scapular plane. JOSPT 27(2): 125-133, 1988.

GH joint with ST contribution seeking a position of stability relative to humerus.

Patterns of Scapular Dyskinesis

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Type I = abnormal motion around a horizontal axis so that the scapula has abnormal anterior tilt; the clinical manifestation is prominence of the inferior medial scapular border on arm motion.

Kibler WB. Management of the scapula in glenohumeral instability.

Techniques in Shoulder & Elbow

Surgery 4(3): 89-98, September 2003.

Patterns of Scapular Dyskinesis

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Type II = abnormal motion around a vertical axis so that the scapula has abnormal lateral or external rotation; the clinical manifestation is prominence of the entire medial scapular border.

Patterns of Scapular Dyskinesis

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Type III = abnormal motion around a sagittal axis so that the medial scapula translates superiorly and the lateral scapula translates inferiorly; the clinical manifestation is prominence of the superior medial border.

Hypermobility

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With Ehlers-Danlos syndrome (EDS), there is tissue laxity and more fragile ligaments and tendons; therefore, the EDS patient is predisposed to joint laxity causing hypermobility, which increases the vulnerability of the joint to injury.

Joint Hypermobility

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Since joint laxity may predispose the person to experience joint instability, then improving joint stability must come from the muscular system.

Joint Stability

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Joint stability by “muscle stiffness” via gamma-muscle spindle system has been found to be one of the important variables in joint stabilization.

•

Muscle stiffness has been described as the “spring-like” quality of muscle.

•

When muscle has high stiffness, increased force is required to cause lengthening of the muscle.

Johansson H, Sjolander P. Receptors in the knee joint ligaments and their role in biomechanics of the joint. CRC Critical Reviews in Biomedical Engineering 18: 341-368, 1991.

Joint Stability

•

In the shoulder, a link has been established between neural structures and mechanoreceptors in the capsule and ligaments of the glenohumeral joint.

Vangsness CT, Ennis M, Taylor JG. Neural anatomy of the glenohumeral ligaments, labrum, and subacromial bursa. Arthroscopy 11: 180-184, 1995.

Joint Stability

•

In the spine, Panjabi found the smaller deeper spinal muscles which attach to the lumbar vertebrae provide ‘segmental stability and control’ rather than ‘movement’.

Panjabi MM. The stabilizing system of the spine. Part I. Function, dysfunction, and adaptation and enhancement. J Spinal Disorders 5: 383-389, 1992.

Panjabi MM. The stabilizing system of the spine. Part II. Neutral zone and instability hypothesis. J Spinal Disorders 5: 390-397, 1992.

Joint Stability

•

Lephart showed proprioception of the symptomatic shoulder was disrupted in patients with glenohumeral instability and improved after shoulder reconstruction.

Muscle Force Couples

• •

Dynamic equilibrium of the glenohumeral joint is attained through efficient function of several force couples acting to stabilize the humeral head during arm movement.

Force couples are muscles that are paired to control the movement or position of a joint or body part.

Shoulder Force Couples

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The rotator cuff muscles help to pull the humeral head into the glenoid of the scapula while the deltoid muscle allows movement of the glenohumeral joint without compressing the rotator cuff muscles in the suprahumeral space.

•

The subscapularis working with the teres minor add an additional force couple.

DELTOID INFRASPINATUS

SUPRASPINATUS DELTOID

Scapular Force Couples

• •

Scapular Protraction (Abduction)

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Upper trapezius and upper digitations of the serratus anterior.

Scapular Retraction (Adduction)

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Upper and lower trapezius, rhomboids and lower digitations of the serratus anterior.

Inman JT, Saunders M, Abbott L. Observations on the function of the shoulder joint. J Bone Joint Surg Am 26: 1-30, 1944.

Happee R, Van der Helm. The control of shoulder muscles during goal directed movements: An inverse dynamic analysis. J Biomech 28: 1179-1191, 1995 .

TRAPEZIUS

SERRATUS ANTERIOR

Scapular Force Couples

• •

Elevation

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Upper trapezius, levator scapula and upper digitations of the serratus anterior.

Depression

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Lower trapezius and lower digitations of the serratus anterior.

LOWER TRAPEZIUS

LOWER SERRATUS ANTERIOR

Neuromuscular Control

• • •

Neuromuscular control exercises are performed in protected positions of the joints.

Usually begin with closed kinetic chain exercises since they enhance compression of the joint and facilitate co-contraction of the agonist antagonist musculature, increasing joint stability.

Then progress to open kinetic chain exercises.

Exercises

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If patient very weak, then start with shoulder isometrics (no motion) in neutral position for shoulder flexion, extension, internal rotation, external rotation, abduction; also scapular adduction with chin tuck seated.

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All exercises have to be performed pain free.

•

Start with 5 second hold for 5 repetitions.

Exercises

• •

Patient has to be educated in proper joint positions, proper technique, avoid heavy lifting, no excessive repetitive movements, and controlling pain while exercising.

Peripheral joints may have to be protected to exercise the shoulders or shoulder girdle.

Exercises

EDS patient may need wrist support to perform TheraBand shoulder exercises.

Exercises

Elbow joint may also need to be protected.

Exercises

•

Closed Kinetic Chain

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Closed Chain Scapular Motion

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Scapular Clocks

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Low Row

–

TheraBand Neutral Shoulder

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TheraBand Scapular Adduction

–

TheraBand Scapular Adduction with Shldr ER

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TheraBand Prone on Elbows Shldr ER

•

Exercises

Closed Kinetic Chain

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Closed Chain Scapular Motion

– – –

Scapular Clocks Low Row TheraBand Neutral Shoulder

–

TheraBand Scapular Adduction

–

TheraBand Scapular Adduction with Shldr ER

–

TheraBand Prone on Elbows Shldr ER

•

Exercises

Closed Kinetic Chain

– – – –

Closed Chain Scapular Scapular Clocks Low Row TheraBand Neutral Shoulder

–

TheraBand Scapular Adduction

–

TheraBand Scapular Adduction with Shldr ER

–

TheraBand Prone on Elbows Shldr ER

•

Exercises

Closed Kinetic Chain

– – – –

Closed Chain Scapular Scapular Clocks Low Row (retraction/ext) TheraBand Neutral Shoulder

–

TheraBand Scapular Adduction

–

TheraBand Scapular Adduction with Shldr ER

–

TheraBand Prone on Elbows Shldr ER

•

Exercises

Closed Kinetic Chain

–

Closed Chain Scapular

– – –

Scapular Clocks Low Row TheraBand Neutral Shoulder

–

TheraBand Scapular Adduction

–

TheraBand scapular Adduction with Shldr ER

–

TheraBand Prone on Elbows Shldr ER

Exercises

•

Closed Kinetic Chain

– – – –

Closed Chain Scapular Scapular Clocks Low Row TheraBand Neutral Shoulder

–

TheraBand Scapular Adduction

–

TheraBand Scapular Adduction with Shldr ER

–

TheraBand Prone on Elbows Shldr ER

•

Exercises

Closed Kinetic Chain

– – – –

Closed Chain Scapular Scapular Clocks Low Row TheraBand Neutral Shoulder

–

TheraBand Scapular Adduction

–

TheraBand Scapular Adduction with Shldr ER

–

TheraBand Prone on Elbows Shldr ER

•

Exercises

Closed Kinetic Chain

– – – –

Closed Chain Scapular Scapular Clocks Low Row TheraBand Neutral Shoulder

–

TheraBand Scapular Adduction

–

TheraBand Scapular Adduction with Shldr ER

–

TheraBand Prone on Elbows Shldr ER

Exercises

•

Closed Kinetic Chain

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Serratus Anterior with TheraBand

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Subscapularis with TheraBand

Exercises

•

Open Kinetic Chain Exercises

– –

Side lying Shldr ER Standing Shoulder Abduction Open Can with DB

– –

Standing Shoulder Flexion with DB Prone Scapular Adduction with Depression

• •

Arms at Side Flexed Elbows, Thumbs Up (Prone Bird)

– –

Prone Lower Trapezius (Super Man) Supine Serratus Anterior with DB

Exercises

•

Open Kinetic Chain Exercises

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Side lying Shldr ER

–

Standing Shoulder Abduction Open Can with DB

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Standing Shoulder Flexion with DB

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Prone Scapular Adduction with Depression

• •

Arms at Side Flexed Elbows, Thumbs Up (Prone Bird)

–

Prone Lower Trapezius (Super Man)

–

Supine Serratus Anterior with DB

Exercises

•

Open Kinetic Chain Exercises

–

Side lying Shldr ER

–

Standing Shoulder Abduction Open Can with DB

–

Standing Shoulder Flexion with DB

–

Prone Scapular Adduction with Depression

• •

Arms at Side Flexed Elbows, Thumbs Up (Prone Bird)

–

Prone Lower Trapezius (Super Man)

–

Supine Serratus Anterior with DB

Exercises

•

Open Kinetic Chain Exercises

– –

Side lying Shldr ER Standing Shoulder Abduction Open Can with DB

–

Standing Shoulder Flexion with DB

–

Prone Scapular Adduction with Depression

• •

Arms at Side Flexed Elbows, Thumbs Up (Prone Bird)

–

Prone Lower Trapezius (Super Man)

–

Supine Serratus Anterior with DB

Exercises

•

Open Kinetic Chain Exercises

– –

Side lying Shldr ER Standing Shoulder Abduction Open Can with DB

–

Standing Shoulder Flexion with DB

–

Prone Scapular Adduction with Depression

• •

Arms at Side Flexed Elbows, Thumbs Up (Prone Bird)

–

Prone Lower Trapezius (Super Man)

–

Supine Serratus Anterior with DB

Exercises

•

Open Kinetic Chain Exercises

–

Side lying Shldr ER

–

Standing Shoulder Abduction Open Can with DB

–

Standing Shoulder Flexion with DB

–

Prone Scapular Adduction with Depression

•

Arms at Side

•

Flexed Elbows, Thumbs Up (Prone Bird)

–

Prone Lower Trapezius (Super Man)

–

Supine Serratus Anterior with DB

Exercises

•

Open Kinetic Chain Exercises

–

Side lying Shldr ER

–

Standing Shoulder Abduction Open Can with DB

–

Standing Shoulder Flexion with DB

–

Prone Scapular Adduction with Depression

•

Arms at Side

•

Flexed Elbows, Thumbs Up (Prone Bird)

–

Prone Lower Trapezius (Super Man)

–

Supine Serratus Anterior with DB

Exercises

•

Open Kinetic Chain Exercises

– –

Side lying Shldr ER Standing Shoulder Abduction Open Can with DB

–

Standing Shoulder Flexion with DB

–

Prone Scapular Adduction with Depression

• •

Arms at Side Flexed Elbows, Thumbs Up (Prone Bird)

–

Prone Lower Trapezius (Super Man)

–

Supine Serratus Anterior with DB

Remember that all exercises have to be performed pain free, with a slower progression, and the patient must maintain all joints in a protected and properly aligned biomechanical position.

170 °

170°

G

Joint Capsule/ Coracohumeral Ligament

180°

Scapulohumeral Rhythm

Scapula = 60° Glenohumeral = 120° SC Jt.- 30° elevation 15° early (35°) AC Jt.

15° late (135°)

Closed Kinematic Chain

Dvir,1978

References

• • • • • • • • • • • • • • • Scapula and Glenohumeral Joint 1.

Barton LM, Bird HA. Improving pain by the stabilization of hyperlax joints.

J Ortho Rheum

9: 46-51, 1996.

2.

Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder; spectrum of pathology part III: the SICK scapula, scapular dyskinesis, the kinetic chain, and rehabilitation.

Arthroscopy

19(6): 641-661, 2003.

3.

Cools AM, Witrouw ES, Declercq GA, Vanderstraeten GG, Cambier DC. Evaluation of isokinetic force production and associated muscle activity in the scapular rotators during a protraction-retraction movement in overhead athletes with impingement symptoms

. Br J Sports Med

38: 64-68, 2004.

4.

DePalma MJ, Johnson EW. Detecting and treating shoulder impingement syndrome: the role of scapulothoracic dyskinesis.

Physician Sportsmed

31(7): 25-32, 2003.

5.

Ekstrom RA, Bifulco KM, Lopau CJ, Anderson CF, Gough JR. Comparing the function of the upper and lower parts of the serratus anterior muscles using surface electromyography.

J Ortho Sports Phys Ther

34(5): 235 243, 2004.5. 6. Hall MG, Ferrell WR, Sturrock RD, et al. The effects of the hypermobility syndrome on knee joint proprioception.

Brit J Rheum

34: 121-125, 1995.

7.

Happee R, Van der Helm. The control of shoulder muscles during goal directed movements: An inverse dynamic analysis.

J Biomech

28: 1179-1191, 1995.

8.

Inman JT, Sanders M, Abbott L. Observations on the function of the shoulder joint.

J Bone Joint Surg Am

26: 1-30, 1994.

9.

Johansson H, Sjolander P. A sensory role for the cruciate ligaments.

Clin Ortho & Related Res

268: 161 178, 1991.

10. Johansson H, Sjolander P. Receptors in the knee joint ligaments and their role in biomechanics of the joint.

CRC Critical Reviews in Biomed Engineering

18: 341-368, 1991.

11. Kibler WB. Shoulder rehabilitation: principles and practice.

Med Sci Sports Exer

30(4): 40-50, 1998.

12. Kibler WB. The role of the scapula in athletic shoulder function.

Am J Sports Med

26: 325-337, 1998.

13. Kibler WB. Management of the scapula in glenohumeral instability.

Techniques in Shoulder & Elbow Surgery

4(3): 89-98, 2003.

14. Kibler WB, Tambay NS. Shoulder inquiry encompasses kinetic chain structures.

Biomechanics

, 49-57, 2005.

References, cont.

• • • • • • • • • • • 15. Magarey ME, Jones MA. Specific evaluation of the function of force couples relevant for stabilization of the glenohumeral joint.

Man Ther

8(4): 247-253, 2003.

16. Mallik AK, Ferrell WR, McDonald AG, Sturrock RD. Impaired proprioceptive acuity at the proximal interphalangeal joint in patients with hypermobility syndrome.

Brit J Rheum

33: 386-398, 1994.

17. McQuade KJ, Smidt GL. Dynamic scapulohumeral rhythm: the effects of external resistance during elevation of the arm in the scapular plane.

JOSPT

27(2): 125-133, 1988.

18. Panjabi MM. The stabilizing system of the spine. Part I. Function, dysfunction adaptation and enhancement. J Spinal Disorders 5: 383-389, 1992.

19. Panjabi MM. The stabilizing system of the spine. Part II. Neutral zone and instability hypothesis.

J Spinal Disorders

5: 390-397, 1992.

20. Rowe CR, Zarins B. Recurrent transient subluxation of the shoulder.

J Bone Joint Surg Am

63: 863-872, 1981.

21. Rubin BD, Kibler WB. Fundamental principles of shoulder rehabilitation: conservative to post operative management.

Arthroscopy

18(9): 29-39, Nov 2002.

22. Russek LN. Examination and treatment of a patient with hypermobility syndrome.

Phys Ther

80: 386-398, 2000.

23. Sharma L. PaiYC. Impaired proprioception and osteoarthritis.

Current Opinion in Rheumatology

3: 253-258, 1997.

24. Shoen RP, Kirsner AB, Farber SJ, Finkel RI. The hypermobility syndrome.

Postgraduate Medicine

71: 199-208, 1982.

25. Takeda Y, Kashiwaguchi S, Endo K, Matsuura T, Sasu T. The most effective exercise for strengthening the supraspinatus muscle.

Am J Sports Med

30: 394-381, 2002.