management of the scapula in glenohumeral instability steven a stratton, pt, phd, atc

Management of the Scapula in Management of the Scapula in Glenohumeral InstabilityGlenohumeral Instability

Steven A Stratton, PT, PhD, ATCSteven A Stratton, PT, PhD, ATC

Steven A. Stratton, PhD, PT, ATCSteven A. Stratton, PhD, PT, ATC

• General Physical TherapyGeneral Physical Therapy

• Orthopaedic Physical TherapyOrthopaedic Physical Therapy

• Manual TherapyManual Therapy

• Spinal RehabilitationSpinal Rehabilitation

• Sports Physical TherapySports Physical Therapy

Shoulder ComplexShoulder Complex

• Sternoclavicular JointSternoclavicular Joint

• Acromioclavicular JointAcromioclavicular Joint

• Glenohumeral JointGlenohumeral Joint

• Scapulothoracic JointScapulothoracic Joint

Shoulder ComplexShoulder Complex

Sternoclavicular Joint

SuperiorSuperiorAnteriorAnterior

Acromioclavicular Joint

Glenohumeral JointGlenohumeral Joint

ShoulderShoulder Capsular-Ligamentous Complex

Scapulothoracic JointScapulothoracic Joint

Scapulothoracic JointScapulothoracic Joint

(Protraction)(Protraction)(Retraction)(Retraction)

Scapular Rest PositionScapular Rest Position

Stability of the Shoulder Stability of the Shoulder ComplexComplex

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

Scapulohumeral RhythmScapulohumeral Rhythm

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

• Likened to a “ball on a seal’s nose”.Likened to a “ball on a seal’s nose”. Rowe CR, Zarins B. Recurrent transient subluxation of the Rowe CR, Zarins B. Recurrent transient subluxation of the

shoulder. shoulder. J Bone Joint Surg AmJ Bone Joint Surg Am 63: 863-872, 1981. 63: 863-872, 1981.


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

Glenohumeral and Glenohumeral and Scapulothoracic ContributionScapulothoracic Contribution

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

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

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

JOSPTJOSPT 27(2): 125-133, 1988. 27(2): 125-133, 1988.

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

Patterns of Scapular DyskinesisPatterns of Scapular Dyskinesis

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

Kibler WB. Management of the Kibler WB. Management of the scapula in glenohumeral instability. scapula in glenohumeral instability. Techniques in Shoulder & Elbow Techniques in Shoulder & Elbow Surgery 4(3):Surgery 4(3): 89-98, September 2003. 89-98, September 2003.


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


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

HypermobilityHypermobility

• 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 HypermobilityJoint Hypermobility

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

Joint StabilityJoint Stability• Joint stability by “muscle stiffness” via Joint stability by “muscle stiffness” via

gamma-muscle spindle system has been gamma-muscle spindle system has been found to be one of the important variables found to be one of the important variables in joint stabilization.in joint stabilization.

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

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

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

Joint StabilityJoint Stability

• In the shoulder, a link has been In the shoulder, a link has been established between neural structures established between neural structures and mechanoreceptors in the capsule and mechanoreceptors in the capsule and ligaments of the glenohumeral and ligaments of the glenohumeral joint.joint.Vangsness CT, Ennis M, Taylor JG. Neural anatomy of the Vangsness CT, Ennis M, Taylor JG. Neural anatomy of the glenohumeral ligaments, labrum, and subacromial bursa. glenohumeral ligaments, labrum, and subacromial bursa. Arthroscopy Arthroscopy 11: 180-184, 1995.11: 180-184, 1995.


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

Panjabi MM. The stabilizing system of the spine. Part I. Function, Panjabi MM. The stabilizing system of the spine. Part I. Function,

dysfunction, and adaptation and enhancement. dysfunction, and adaptation and enhancement. J Spinal DisordersJ Spinal Disorders

5: 383-389, 1992.5: 383-389, 1992.

Panjabi MM. The stabilizing system of the spine. Part II. Neutral Panjabi MM. The stabilizing system of the spine. Part II. Neutral

zone and instability hypothesis. zone and instability hypothesis. J Spinal DisordersJ Spinal Disorders 5: 390-397, 5: 390-397,

1992.1992.


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

Muscle Force CouplesMuscle Force Couples

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

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

Shoulder Force CouplesShoulder Force Couples

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

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

DELTOID

INFRASPINATUSINFRASPINATUS

DELTOID

SUPRASPINATUS

Scapular Force CouplesScapular Force Couples

• Scapular Protraction (Abduction)Scapular Protraction (Abduction)– Upper trapezius and upper digitations of the Upper trapezius and upper digitations of the

serratus anterior.serratus anterior.• Scapular Retraction (Adduction)Scapular Retraction (Adduction)

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

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

Happee R, Van der Helm. The control of shoulder muscles during goal directed Happee R, Van der Helm. The control of shoulder muscles during goal directed

movements: An inverse dynamic analysis. movements: An inverse dynamic analysis. J Biomech 28: 1179-1191, 1995 28: 1179-1191, 1995..

TRAPEZIUS

SERRATUS ANTERIOR

Scapular Force CouplesScapular Force Couples

• ElevationElevation– Upper trapezius, levator scapula and upper Upper trapezius, levator scapula and upper

digitations of the serratus anterior.digitations of the serratus anterior.

• DepressionDepression– Lower trapezius and lower digitations of Lower trapezius and lower digitations of

the serratus anterior.the serratus anterior.

LOWER TRAPEZIUS

LOWERSERRATUS ANTERIOR

Neuromuscular ControlNeuromuscular Control• Neuromuscular control exercises are Neuromuscular control exercises are

performed in protected positions of the performed in protected positions of the joints.joints.

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

• Then progress to open kinetic chain Then progress to open kinetic chain exercises.exercises.

ExercisesExercises• If patient very weak, then start with If patient very weak, then start with

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

• All exercises have to be performed pain All exercises have to be performed pain free.free.

• Start with 5 second hold for 5 repetitions.Start with 5 second hold for 5 repetitions.

ExercisesExercises

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

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

ExercisesExercises

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

ExercisesExercises

Elbow joint may also Elbow joint may also need to be need to be protected.protected.

ExercisesExercises

• Closed Kinetic ChainClosed Kinetic Chain– Closed Chain Scapular MotionClosed Chain Scapular Motion– Scapular ClocksScapular Clocks– Low RowLow Row– TheraBand Neutral ShoulderTheraBand Neutral Shoulder– TheraBand Scapular AdductionTheraBand Scapular Adduction– TheraBand Scapular Adduction with Shldr TheraBand Scapular Adduction with Shldr

ERER– TheraBand Prone on Elbows Shldr ERTheraBand Prone on Elbows Shldr ER

ExercisesExercises• Closed Kinetic ChainClosed Kinetic Chain

– Closed Chain Closed Chain Scapular MotionScapular Motion

– Scapular ClocksScapular Clocks– Low RowLow Row– TheraBand Neutral TheraBand Neutral

ShoulderShoulder– TheraBand Scapular TheraBand Scapular

AdductionAdduction– TheraBand Scapular TheraBand Scapular

Adduction with Shldr Adduction with Shldr ERER

– TheraBand Prone on TheraBand Prone on Elbows Shldr ERElbows Shldr ER


– Closed Chain ScapularClosed Chain Scapular– Scapular ClocksScapular Clocks– Low RowLow Row– TheraBand Neutral TheraBand Neutral






– Closed Chain ScapularClosed Chain Scapular– Scapular ClocksScapular Clocks– Low Row Low Row (retraction/ext)(retraction/ext)

– TheraBand Neutral TheraBand Neutral ShoulderShoulder

– TheraBand Scapular TheraBand Scapular AdductionAdduction

– TheraBand Scapular TheraBand Scapular Adduction with Shldr Adduction with Shldr ERER



– Closed Chain Closed Chain ScapularScapular

– Scapular ClocksScapular Clocks– Low RowLow Row– TheraBand Neutral TheraBand Neutral


AdductionAdduction– TheraBand scapular TheraBand scapular







Adduction with Shldr ERAdduction with Shldr ER– TheraBand Prone on TheraBand Prone on

Elbows Shldr ERElbows Shldr ER

ExercisesExercises

• Closed Kinetic Closed Kinetic ChainChain– Serratus Anterior Serratus Anterior

with TheraBandwith TheraBand

– Subscapularis with Subscapularis with TheraBandTheraBand

ExercisesExercises• Open Kinetic Chain ExercisesOpen Kinetic Chain Exercises

– Side lying Shldr ERSide lying Shldr ER– Standing Shoulder Abduction Open Can Standing Shoulder Abduction Open Can

with DBwith DB– Standing Shoulder Flexion with DBStanding Shoulder Flexion with DB– Prone Scapular Adduction with Prone Scapular Adduction with

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

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

ExercisesExercises• Open Kinetic Chain Open Kinetic Chain

ExercisesExercises– Side lying Shldr ERSide lying Shldr ER– Standing Shoulder Standing Shoulder

Abduction Open Can with Abduction Open Can with DBDB

– Standing Shoulder Flexion Standing Shoulder Flexion with DBwith DB

– Prone Scapular Adduction Prone Scapular Adduction with Depressionwith Depression

• Arms at SideArms at Side• Flexed Elbows, Thumbs Up Flexed Elbows, Thumbs Up

(Prone Bird)(Prone Bird)

– Prone Lower Trapezius Prone Lower Trapezius (Super Man)(Super Man)

– Supine Serratus Anterior Supine Serratus Anterior with DBwith DB

ExercisesExercises

• Open Kinetic Chain ExercisesOpen Kinetic Chain Exercises– Side lying Shldr ERSide lying Shldr ER– Standing Shoulder Abduction Standing Shoulder Abduction

Open Can with DBOpen Can with DB– Standing Shoulder Flexion Standing Shoulder Flexion

with DBwith DB– Prone Scapular Adduction Prone Scapular Adduction

with Depressionwith Depression• Arms at SideArms at Side• Flexed Elbows, Thumbs Up Flexed Elbows, Thumbs Up



– Supine Serratus Anterior with Supine Serratus Anterior with DBDB

ExercisesExercises• Open Kinetic Chain Open Kinetic Chain

ExercisesExercises– Side lying Shldr ERSide lying Shldr ER– Standing Shoulder Standing Shoulder

Abduction Open Can with Abduction Open Can with DBDB

– Standing Shoulder Flexion Standing Shoulder Flexion with DBwith DB

– Prone Scapular Adduction Prone Scapular Adduction with Depressionwith Depression

• Arms at SideArms at Side• Flexed Elbows, Thumbs Up Flexed Elbows, Thumbs Up

(Prone Bird)(Prone Bird)– Prone Lower Trapezius Prone Lower Trapezius

(Super Man)(Super Man)– Supine Serratus Anterior Supine Serratus Anterior

with DBwith DB

ExercisesExercises• Open Kinetic Chain ExercisesOpen Kinetic Chain Exercises

– Side lying Shldr ERSide lying Shldr ER– Standing Shoulder Abduction Standing Shoulder Abduction

Open Can with DBOpen Can with DB– Standing Shoulder Flexion Standing Shoulder Flexion

with DBwith DB– Prone Scapular Adduction Prone Scapular Adduction

with Depressionwith Depression• Arms at SideArms at Side• Flexed Elbows, Thumbs Up Flexed Elbows, Thumbs Up



– Supine Serratus Anterior with Supine Serratus Anterior with DBDB

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

170 °

G

Joint Capsule/Joint Capsule/Coracohumeral Coracohumeral LigamentLigament


180°

Scapula = 60°

Glenohumeral = 120°

SC Jt.- 30° elevation

AC Jt.15° early (35°)

15° late (135°)

Closed Kinematic ChainClosed 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.

management of the scapula in glenohumeral instability steven a stratton, pt, phd, atc

Documents

joint instability

abnormal motion

lateral scapula

arm motion

joint stabilityjoint

entire medial scapular

abnormal lateral

j bone joint surg