Kibler et al reported the reliability of a visually based classification system for scapular dysfunction that defined 3 different types of motion abnormalities: type 1 . PDF | Introduction Scapular dyskinesis is a condition responsible for Type III dyskinesis with posterior prominence of the inferomedial angle, Management Scapular dyskinesis: Diagnosis and treatment R Postacchini 1 *, S. Mobility Myths with Dr. Quinn | Scapular Winging | – Duration: 13 Juggernaut Training Systems , views ·
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Historically, scapular dyskinesia has been used to describe an isolated clinical entity whereby an abnormality in positioning, movement or function of the scapula is present. Based upon this, treatment approaches have focused on addressing local isolated muscle activity. Recently, however, there has been a progressive move towards viewing the scapula as being part of a wider system of movement that is regulated and controlled by multiple factors, including the wider kinetic chain and individual patient-centred requirements.
We therefore propose a paradigm shift whereby scapular dyskinesia is seen not in isolation but is considered within the broader context of patient-centred care and an entire neuromuscular system.
This is because the scapula must upwardly and externally rotate and posteriorly tilt adequately to prevent the humeral head from compressing and shearing against the under surface of the acromion: Based on this widely held view, the aim of many shoulder rehabilitation programmes is to correct aberrant, local scapula mechanics.
The notion of scapular dyskinesis for the purposes of the present review does not include presentations where there is a defined abnormality of the neuromuscular system; for example, neuritis, neuropathy, neuropraxia or other forms of peripheral nerve injury. The purpose of the present review is to summarize current concepts and provide the clinician with not only a foundation of reasoning on which to base clinical decision-making, but also some practical suggestions as to how these could be incorporated and utilized in daily practice.
Scapulohumeral rhythm SHR is the co-ordination between humeral and scapular movements and was first described by Codman 2 and subsequently popularized by Inman.
With the benefit of time and technology, it is clear that SHR is much more complex than the reported 2: Ratios are characteristically inconsistent, suggesting that the relationship is variable and nonlinear.
There are also variations of scapular movement within individuals depending on the speed at which movement is performed, 8 the load used, 9 whether movement is concentric or eccentric 10 and is performed unilaterally or bilaterally 11 or even the hand dominance of the subject.
Diskinessia quantitative and qualitative methods are of little clinical value when it is considered that:. There is also the problem of relevance.
Scapular dyskinesia: evolution towards a systems-based approach
If the subject of the measurement in this case whether or not ttipo scapula is dyskinetic is a flawed concept, then the tests themselves are of limited use. As has happened so many times in our profession, the original concept of a pure, delineated and possibly dogmatic theory and its associated assessment has, over time and with a growing body of research become questionable. The traditional model of assessment of scapular dyskinesis appears to be becoming more implausible Table 1.
The evidence challenging the existence of and the assessment for scapular dyskinesis is broad based but, to compound matters, it would appear that attempts to correct identified scapular dyskinesis with rehabilitation are largely unsuccessful. The identified dyskinesis, however, did not change. The whole concept of scapula dyskinesis as an isolated condition is therefore facing some kind of existential crisis.
Perhaps it does not exist at all. It would be remiss at this point to advocate the dissolution of all things pertaining to aberrant scapula humeral rhythm and throw the baby out with the kinematic bathwater.
Whether it is subjectively labelled as normal or abnormal, what is observed is the association and interdependence of the neuromusculoskeletal system around the trunk, shoulder girdle and wider kinetic chain. diskinseia
The end result should be production of smooth, controlled movement between the humeral and scapula components of movement and this requires significant co-ordination. It is perhaps time to evolve our thinking and move towards a systems-based approach.
During the course of movement, muscles almost never work in isolation. Co-ordinated, controlled movement is the outcome of a functioning neuromuscular system. If something goes wrong with the movement, it could be attributed to any part of the system.
The complexity of this extraordinary process is reliant on an integrated process of sensoriomotor control. Such control requires successful interaction of its component parts such as the motor cortex, thalmic system and cerebellum, as well as higher cognitive functions such as perception.
International Journal of Orthopaedics
The very nature of the complexity and the interdependency of all the escapjlar required for motor control render the existence of a litmus test for the presence of scapular dyskinesis extremely unlikely and the search for one a potentially fruitless task.
Over the last decade, there has been a gradual move in the assessment of musculoskeletal conditions from the limited value of the traditional orthopaedic test toward a more global, systems-based approach. The publication of the shoulder symptom modification escapulaf SSMP 28 signalled a paradigm shift in the way shoulder assessment was conducted. Such interventions include thoracic postural correction, scapula movement facilitation, humeral head procedures and neuromodulation procedures.
If successful, the facilitation of these muscle groups can be incorporated into early treatment programmes. As a result ciskinesia its close association with the wider kinetic chain, techniques to reduce the appearance of dyskinesis by incorporating elements chain activity e.
The exact tjpo by which these procedures reduce symptoms is unknown but, clinically, it appears that, by accessing posterior rotator cuff activity via glenohumeral external rotation, a patient with diskinedia could be described as visible scapular dyskinesis performs this manoeuvre and, as far as the limitations of visual observation allow, the dyskinesis significantly reduces or disappears altogether.
If accompanied by a reduction in pain, this would be a favourable response to the procedure. It is escapullar not alterations to the appearance of dyskinesis per se that is the intended aim of the improvement tests but rather the reduction in reported symptoms that can be achieved with their use.
The fact that such a spectrum of different interventions all have the potential to reduce the dyskinesis introduces another thought dimension.
Subgroup analysis of which type of patients respond best to which type of intervention would be revealing. However, no such riskinesia measures have been validated and clinicians do not have the luxury of waiting until they are. In an attempt to signpost therapists or indeed our surgical colleagues, the assessment tools in Fig. However, some elements are easier to integrate than others. If, however, humeral diskniesia or scapular upward rotation improves the patients symptoms, then this is less straightforward.
Scapular upward rotation is not a movement that exists in isolation and the translational anterior posterior glide movement of humeral head facilitation requires an externally applied pressure.
The challenge then becomes finding an exercise that capitalizes on the symptom reduction achieved during symptom modification. For this, clinical reasoning needs to take esapular step further and this is significantly aided by understanding the roles and function of diskinesiaa scapula and rotator cuff.
When glenohumeral movement occurs, the scapula must also move to allow the repositioning of the glenoid fossa thus increasing the available range of movement. During this movement, the scapulohumeral and axioscapular muscles must collectively function diskinesiq maintain optimal mechanical alignment. Rotator cuff activity prevents unwanted humeral head translation but, when left unchecked, would pull the scapula laterally, essentially creating a destabilizing force. The axioscapular muscles respond by preventing the scapulohumeral muscles from destabilizing the scapula and produce the upward rotation, posterior tilting and externally rotate necessary for optimal movement and function.
Just like the rotator cuff, scapula muscles have multiple roles which ecsapular, dependent on the task, the load, the speed or the range in which the movement is occurring. Glenohumeral external rotation exercises, for example, are classically regarded as working the rotator cuff in its agonist role.
This is true, but it is also true of all shoulder rotator torque generators and is therefore not specific to the rotator cuff. Glenohumeral external rotation however also requires the scapular muscles to function in eescapular stabilizing role, explaining why either static or dynamic rotation utilized through symptom modification procedures can change apparent scapula dyskinesis. In escapullar to their agonistic role specific shoulder muscles also stabilize against destabilizing forces created by other shoulder muscles but this is far from static.
Rotator cuff muscles prevent unwanted translation of the diskinsia head caused by other humeral muscles e. Axioscapular muscles work against the destabilizing force of the scapulohumeral muscles to prevent the scapulohumeral muscles from translating escapu,ar scapula off the thoracic cage.
To rehabilitate the stabilizing function of the axioscapular muscles and also, by virtue of their interdependence, the rotator cuffit is perhaps more useful to consider strategies that allow the shoulder complex to react to de-stabilizing forces.
Delayed activation of serratus anterior in the early stages of movement has been implicated as a potential source of scapula dyskinesis in patients with shoulder symptoms. When interpreting assessment findings it is perhaps helpful to consider the process outlined in Fig. Given their interdependence, a thorough assessment of the rotator cuff should also be conducted Fig.
Through range assessment of the rotator cuff.
A Clinical Method for Identifying Scapular Dyskinesis, Part 1: Reliability
The scapula is stabilized and therefore not working in its dynamic role. If weakness of a portion of the rotator cuff is found, together with the findings from symptom modification tests, a clearer picture about where to start with rehabilitation may start to materialize. An example of this process is shown in Fig. The kinetic chain elements of assessment should not be forgotten. Single leg standing or tip toe standing may not have resulted in the most significant change with symptom modification but they remain a significant part of the bigger picture.
If the humeral contingent of the system is unable to perform a pattern of movement without the involvement of the scapular muscles, the scapula is unfairly implicated as the culprit when it is being utilized in an unconventional way in an attempt to maintain function. Similarly, the dyskinesis may not become apparent until the task becomes more complicated and involves co-ordination with the wider chain.
Patients may also present differently in an open or closed chain position Fig. The key to success with this approach to rehabilitation is having a sound appreciation of what the scapula and rotator cuff muscle groups are doing with each exercise, why they may or may not be beneficial, and how to adapt them if the patient is unable to perform them without compensatory movements or symptoms.
With this knowledge and armed with some clinical reasoning, creativity and often trial and error, it should be possible to find at least one exercise that a patient can leave with, empowered by the knowledge that they can affect their own symptoms with movement. As previously noted, it is difficult to justify a position of claiming that a patient is undergoing rotator cuff or scapula specific rehabilitation.
What one exercise may do more than another, however, is bias the exercise towards a situation where, for example, the scapula is only working in a static stabilizing, rather than a dynamic stabilizing role, where the former is generally considered an easier or less complex task.
The interdependence of the scapula, rotator cuff and kinetic chain requires clinicians to question the desirability of isolating one part of the system from the other. If the scapular and rotator cuff components are required to work together functionally, they should be trained as such. Furthermore, it is also not possible to isolate single muscles within a single exercises.
Even activities that demonstrate maximum activation do not do so to the exclusion of other muscles. The flowchart in Fig.
The exercises pictured in Fig. Over recent years, there have been a wealth of studies utilizing electromyographic EMG data. Exercise progression using a systems-based approach would instead focus not on biomechanically correcting the scapula position but, instead, on regaining and retraining the whole motor control pattern that had been identified through careful assessment, in terms of being problematic for that patient Fig.
A functioning proprioceptively mediated motor control system requires co-ordination, and therefore integration, of all the different body parts throughout the kinetic chain necessary for that particular movement pattern.
For the shoulder, this tupo require assessment of the constituent parts working in both their agonist and stabilizer roles throughout full ranges of both concentric and eccentric phases of movement. It will also necessitate involvement of the wider kinetic chain to train relevant motor patterns that resemble the functional demands of the patient.
In the early stages of rehabilitation, it may be necessary to limit the number of simultaneous functions that the patient is required to perform. Low load, unsupported shoulder rotation tasks can be used to train complex normal motor patterns; therefore, the early part of the motor pattern can be recruited and retrained in the appropriate manner. As rehabilitation progresses, the patient is challenged to maintain the correct motor pattern despite the increasing demand and complexity of the relevant task.
This may involve elements of speed, co-ordination, load and specific functional requirements relevant to the individual, until a normal, fully functioning motor control pattern can be established and, crucially, reinforced with repetition. By utilizing the secapular principles of motor learning and skill attainment with what is understood about proprioceptively mediated musculoskeletal rehabilitation, we can use our skills to their full potential.
The coalescence of assessment and treatment techniques results in a symptoms and escapulsr approach that is patient-centred and relevant to the functional requirements of the individual. We advocate that this has advantages over a traditional biomechanical model that utilizes assessment principles focused on minute differences in centimetres and degrees and deviations from a normal that arguably do not exist. National Center for Biotechnology InformationU. Journal List Shoulder Elbow v.
Published online Dec Author information Article notes Copyright and License information Disclaimer. Received Oct 20; Accepted Oct