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The Scapula Counts Too!

Incorporating Scapular Exercises


into
Shoulder Rehabilitation
Brady L. Tripp PhD, ATC
Florida International University

Mini-course Goals
This course is designed for clinicians who wish to enhance their
ability to assess and rehabilitate shoulder dysfunction. We will
discuss and practice advanced clinical techniques to assess scapular
function and integrate scapula control exercises into shoulder
rehabilitation.
We will review material using brief PowerPoint presentations
followed by demonstrations and hands-on experience applying the
assessment and rehabilitation techniques.
We will
z Review the role of scapula in shoulder function and dysfunction
z Demonstrate and practice clinical assessment techniques and special
tests to evaluate scapular function
z Identify and discuss components of scapular rehabilitation
z Demonstrate and practice methods to integrate scapular stability
exercises into shoulder rehabilitation

Dr. Tripps Tips for Shoulder


Rehabilitation

Agenda
1. Clinical Exam
2. Shoulder Foundation Understanding Function of the Scapula
Components of Scapular Control
3. Posture / Postural Awareness
4. Flexibility, Neuromuscular Control, Strength and Endurance
Developing Stability
5. Continuum of Stability
6. Engraining Functional Stability
Integrating Scapular Control into Rehabilitation
7. Progressive Variation
Take Home Points
Questions

1. Clinical exam is VITAL!


2. Proximal stability is the foundation for distal stability, mobility
and function
3. Poor posture / postural awareness and pain inhibit progress
4. Stability requires flexibility, neuromuscular control, strength
and endurance
5. Stability is a continuum, develop it as a continuum
static dynamic functional
1-joint multi-joint functional

6.
7.

Engrain motor patterns that begin with scapular setting


Use progressive variation to increase demands of exercises;
follow established progression sequence

Primary Functions of the Scapula


The Scapula a Mobile and Stable Base

Clinical Exam and Scapular Function


Goal: Identify issues, eliminate concerns and develop goals





Adequate visualization of landmarks


Multiple repetitions of flexion and scaption
Adding 1-5 lb weights may help identify deficits
Classify scapular motion as NORMAL
or
ABNORMAL

Clinical Exam is VITAL!


How would you describe
what is going on here?
Scapula must move consistently with humerus

Scapular Motion
Goal = Identify issues
NORMAL and ABNORMAL Scapular Motion
 Rotations about 3 axes, in 3 planes




Upward / Downward Rotation


Internal / External Rotation
Anterior / Posterior Tilt

Superior / Inferior Translation (shrug)

Scapular Upward Rotation

Scapular Upward Rotation


Axis of
Rotation

Sagittal

Plane of
Motion

Frontal

Resting
Position

2 5

Normal
Range

50 5

Scapular Upward Rotation

Resting Position

2 5

Resting Position

2 5

Normal Range

50 5

Normal Range

50 5

Scapular External Rotation


Axis of
Rotation

Vertical

Plane of
Motion

Transverse

Resting
Position

-30 15

Normal
Range

25 10

Scapular External Rotation

Scapular External Rotation


Resting Position

-30 15

Normal Range

25 10

Scapular Posterior Tilt


Resting Position
Normal Range

-8 5
30 15

Resting Position

-30 15

Normal Range

25 10

Scapular Posterior Tilt


Axis of
Rotation

Horizontal

Plane of
Motion

Sagittal

Resting
Position

-8 5

Normal
Range

30 15

Scapular Posterior Tilt


Resting Position
Normal Range

-8 5
30 15

Clinical Exam


Clinical Exam

Classify scapular motion as normal or abnormal


Abnormal compared to what?
Different compared to: 1) ideal
= abnormal
2) the other side = asymmetric
3) other reps
= inconsistent
Ideal scapular motion as the arm elevates :

Normal or Abnormal Scapular Motion?


How do we quantify abnormal?

smooth increases in UR, ER and PT


as the arm is lowered

smooth decreases in UR, ER and PT





The humerus is elevating smoothly, the scapula should follow


The scapula must maintain a stable alignment with the humerus,
if not we lose dynamic stability

Abnormal Upward Rotation

Clinical Exam

EXAMPLES

Abnormal Upward Rotation

Abnormal Upward Rotation


Lack of adequate UR or poor NMC-inconsistency

Shrug initiates movement = superior translation during


elevation

Result: less subacromial


space, greater
tuberosity closer to
coracoacromial arch

Abnormal Upward Rotation

Abnormal Scapular External Rotation

Abnormal Scapular External Rotation

Lack of Scapular External Rotation

Lack of ER or poor NMC-inconsistency

Medial border becomes prominent, lifting off the


thoracic wall

Result:

Increased scapulo-humeral angle


(transverse plane)
Decreases space between
supraspinatus
and posterior superior glenoid
(i.e. posterior impingement)

Abnormal Scapular External Rotation

Abnormal Scapular External Rotation

Abnormal Posterior Tilt

Abnormal Posterior Tilt

Lack of adequate PT or poor NMC-inconsistency

Inferior angle becomes prominent, lifting off the


thoracic wall posteriorly
Result: Decreases subacromial
space, bring greater
tuberosity closer to
coracoacromial arch
(i.e. subacromial
impingement)

Abnormal Posterior Tilt

Abnormal Posterior Tilt

Abnormal Scapular Motion :


Research Findings
Three characteristics were quantified in patients
classified as having abnormal kinematics and
in pathologic subjects
1. less total IR/ER
2. less consistent IR/ER
3. less consistent UR

Abnormal Scapular Motion :


Research Findings
Impingement Patients
( Warner 1992, Lukasiewicz 1999, Ludwig 2000, Hebert 2002 )





Less UR, delayed UR or a more superior


position on thorax (2cm)
Less ER
Less PT (~9)
 May anteriorly tilt
as the arm elevates

Dr. Tripps Tips


for Shoulder Rehabilitation

Clinical Exam
PRACTICAL EXAMPLES
Goal = Identify

1.
2.

Clinical exam is VITAL!


Goal: Identify issues, eliminate concerns and develop goals
Proximal stability is the foundation for distal stability, mobility and function
Goal: Build the foundation early (scapular control) before progressing
distally

1. Normal Scapular Motion


2. Abnormal Scapular Motion
 Asymmetric?
 Inconsistent?
 Lack of: Upward Rotation (shrug)?
External Rot. (medial border prominent)
Posterior Tilt (inferior angle prominent)

Agenda
1. Clinical Exam
2. Shoulder Foundation Understanding Function of the Scapula
Components of Scapular Control
3. Posture / Postural Awareness
4. Flexibility, Neuromuscular Control, Strength and Endurance
Developing Stability
5. Continuum of Stability
6. Engraining Functional Stability
Integrating Scapular Control into Rehabilitation
7. Progressive Variation
Take Home Points
Questions

Dr. Tripps Tips


for Shoulder Rehabilitation
1.
2.
3.

Clinical exam is VITAL!


Goal: Identify issues, eliminate concerns and develop goals
Proximal stability is the foundation for distal stability, mobility and function
Goal: Build the foundation early (scapular control) before progressing
distally
Poor posture / postural awareness and pain inhibit progress
Goal: Address posture and pain first

Components of Scapular Control


Posture: Forward Head / Kyphosis / Slouching
( Ludwig 1996, Kebaetse 1998 )


Result:
Scapula: less PT (~4 less)
less UR (~5 less)
a more superior position
on thorax
GH Joint: less shoulder abduction
(~24less)

Muscular Inflexibility
Pectoralis Minor or Biceps (short head)
Pulls coracoid anterior/inferiorly
 Result: Decreased ER and PT,
fwd rounded shoulders

What does that mean


for this guy?
Rehab Goals
Address Posture!
&
Postural Awareness!

Components of Scapular Control




Serratus Anterior

Fatigue
Tsai, McClure 2003

PT, ER, UR
 McQuade, 1998
 loss of scapular control
 McQuade, 1995

PT, UR


Rehab Goals
Build Endurance!
Maintain Form!

What does that mean


for these guys?

Muscular Weakness / Neurological


Lower and Middle Trapezius


Muscular Weakness / Neurological

Result: During arm elevation: less UR,


lack of PT (tilts anteriorly),
lack of ER (internally rotates),
poor NMC of UR,PT,ER
Plus Sign positive= medial border
is not held on thoracic wall
Scapular Flip Sign positive= medial
border is not held on thoracic wall
Overhead athletes with impingement display
delayed activation of Lower and Middle Trap
during arm elevation (Cools, 2003)

Effecting Scapular Position


To increase upward rotation, external rotation,
posterior tilt:
 Strengthen:
Serratus Anterior
Lower and Middle Traps
 Increase Flexibility, Limit Dominance:
Upper Trap and Levator
Pec Minor

Result: During arm elevation: less UR, less PT,


poor NMC of UR,PT,ER
Plus Sign positive= medial border is
not held on thoracic wall
Scapular Flip Sign positive= medial
border is not held on thoracic wall
Pathologic shoulders display decreased Serratus
Anterior activity during arm elevation
(Ludwig, 2000)

Muscular Dominance / Inflexibility


Upper Trapezius
Shrug initiates movement =
superior translation during
elevation
 Result: During arm elevation:
lack of adequate UR,
poor NMC of UR
 Pathologic shoulders displayed
increased EMG during arm
elevation with a load
(Ludwig, 2000)

Scapular Retraction Test


During Active Flexion:
Examiner: one hand supporting the
elbow/forearm, the other hand retracting
and posteriorly tilting the scapula.
Positive Finding:
Improved strength
Reduction or elimination of symptoms

Who will rehab help?

Dr. Tripps Tips


for Shoulder Rehabilitation

Scapular Assistance Test


During Active Flexion:
Examiner: one hand stabilizing root of
scapular spine, assisting upward rotation;
the other assisting posterior tilt at the
inferior angle
Positive Finding:
Improved strength
Reduction or elimination of symptoms

1.
2.
3.
4.

Agenda
1. Clinical Exam
2. Shoulder Foundation Understanding Function of the Scapula
Components of Scapular Control
3. Posture / Postural Awareness
4. Flexibility, Neuromuscular Control, Strength and Endurance
Developing Stability
5. Continuum of Stability
6. Engraining Functional Stability
Integrating Scapular Control into Rehabilitation
7. Progressive Variation
Take Home Points
Questions

Developing Stability
Stability is a continuum, develop it as a continuum
single multi-joint functional
static dynamic functional
Rhythmic Stabilization

Create a Stable Base!

1.
2.
3.
4.
5.

Create a Stable Base!

Examples?

Scapular Clock

Create a Mobile Base!

Dr. Tripps Tips


for Shoulder Rehabilitation

Developing Stability
Engrain motor patterns that begin with scapular setting

Clinical exam is VITAL!


Goal: Identify issues, eliminate concerns and develop goals
Proximal stability is the foundation for distal stability, mobility and function
Goal: Build the foundation early (scapular control) before progressing
distally
Poor posture / postural awareness and pain inhibit progress
Goal: Address posture and pain first
Stability requires flexibility, neuromuscular control, strength and
endurance
Goal: Develop each component of stability

6.

Clinical exam is VITAL!


Goal: Identify issues, eliminate concerns and develop goals
Proximal stability is the foundation for distal stability, mobility and function
Goal: Build the foundation early (scapular control) before progressing
distally
Poor posture / postural awareness and pain inhibit progress
Goal: Address posture and pain first
Stability requires flexibility, neuromuscular control, strength and
endurance
Goal: Develop each component of stability
Stability is a continuum, develop it as a continuum
static dynamic functional; single multi-joint functional
Goal: Develop stability as a continuum progressing to functional
Engrain motor patterns that begin with scapular setting
Goal: Emphasize beginning movement with a stable base

Agenda
1. Clinical Exam
2. Shoulder Foundation Understanding Function of the Scapula
Components of Scapular Control
3. Posture / Postural Awareness
4. Flexibility, Neuromuscular Control, Strength and Endurance
Developing Stability
5. Continuum of Stability
6. Engraining Functional Stability
Integrating Scapular Control into Rehabilitation
7. Progressive Variation
Take Home Points
Questions

Progressive Variation

Integrating Scapular Control


into Rehabilitation
Clinical Exam Identifies Goals
 Build the foundation early (scapular control) before

progressing distally
 Address posture and pain first
 Develop each component of stability
 Develop stability as a continuum progressing to functional
 Emphasize beginning movement with a stable base

Use Progressive Variation to modify


exercises to achieve Goals

Integrating Scapular Control


into Rehabilitation

Exercise Variables Clinicians Can Manipulate to Advance


Demands and Address Goals of Rehabilitation

EXAMPLES

Examples
Progressive Variation

Examples
Progressive Variation

10

Exercises

Examples
Progressive Variation

Inferior Glide

Robbery

Video

Exercises

Exercises

Low Row

Scapular Clocks

Lawnmower

Rhythmic Stabilization

Exercises

Exercises

Progression

Forward Punch
Downward Rows

Push-ups with +

11

Anterior Shoulder Flexibility

Examples
Address Posture / Increase Flexibility
Internal Rotation and Posterior Capsule (GIRD)
Sleeper Stretch

Agenda
1. Clinical Exam
2. Shoulder Foundation Understanding Function of the Scapula
Components of Scapular Control
3. Posture / Postural Awareness
4. Flexibility, Neuromuscular Control, Strength and Endurance
Developing Stability
5. Continuum of Stability
6. Engraining Functional Stability
Integrating Scapular Control into Rehabilitation
7. Progressive Variation
Take Home Points
Questions

Muscles attaching to the coracoid






Pectoralis minor
Short head of the biceps
Coracobrachialis

Take Home Points


1. Clinical exam is VITAL!
2. Proximal stability is the foundation for distal stability, mobility
and function
3. Poor posture / postural awareness and pain inhibit progress
4. Stability requires flexibility, neuromuscular control, strength
and endurance
5. Stability is a continuum, develop it as a continuum
static dynamic functional; single multi-joint functional

6. Engrain motor patterns that begin with scapular setting


7. Use progressive variation to increase demands of exercises;
follow established progression sequence

Thank You
Questions?

12

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