Disclosures - PDF Document

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  1. 9/7/2018 Disclosures • mTrigger • Litecure Training for the Scapulothoracic Joint and Thoracic Spine Russ Paine, PT Director - UT Physicians Sportsmedicine Rehabilitation Houston, Texas Texas Medical Center Houston Scapular Control • 21 academic institutions 14 hospitals • 33.8 million sq. ft. patient care • 20K MD’s, scientist, advanced degreed • 14 billion annual economic impact • 93,500 employees • 6.0 million patient visits • Review biomechanics • Evaluation Techniques • Thoracic spine • Scapular Strengthening techniques Scapular Muscles Stabilization & Rotation Stability Principles Dynamic Stability • Rotator cuff functions to compress humeral head into glenoid • Scapular muscles position glenoid • Scapular positioning changes muscle force vectors • Serratus Anterior • Rhomboids • Levator Scapulae • Trapezius 1

  2. 9/7/2018 Scapular Muscles Extrinsics Function of Scapula • Scaffold for attachments • Positions glenoid • Allows UE movement • Thoracic spine interplay • Deltoid • Biceps, Triceps • Pectoralis Minor • Lack of scapular strength may lead to reverse contraction: deltoid downwardly rotates scapula instead of lifting humerus • Action counteracted by rhomboids lower trap Why Thoracic Spine Extension? • Decreased extension may lead to compensation • Increased arm extension required placing more stress on anterior shoulder • Possible increase in lumbar spine extension to compensate • Incr. T-rot towards non throwing side – pitchers Laudner IJSPT 2013 Ericcreessey.com Swing and Injury • Body must follow F direction • If body follows altered position of ground F, postural alterations lead to injury • Finds anatomic weakest link • Not an easy game! • Kevin Kirk! Thoracic Manipulation/Mobs Thoracic Control • Begin with mobs and isometric hold 2

  3. 9/7/2018 Thoracic/Rib mobilization Imbalanced Rotation Thoracic Control • Over-rotation of thoracic spine • Common in throwers, golfers • Use ribs to mobilize T- Spine • Progress to active extension with mob Thoracic Spine Advanced Strengthening • Swiss Ball Extensions Thoracic Spine Rotation Strengthening • Now have extension improvement • Begin Thoracic Rotation Strengthening • If imbalance may elect to de-rotate • Both directions Biomechanics of Scapular Motion Desired Position in Normal Shoulder Open Space • Upward rotation, Posterior tilting, External rotation • Allows maximum subacromial clearing • Upward & Downward Rotation • Anterior & posterior Tilting/Tipping • Internal & External Rotation • Which is predominate motion? 3

  4. 9/7/2018 Measuring Scapular Position • Hands below waist = push • Active elevation = observe timing • Kibler - 3 positions • Sobush JOSPT ‘96 = Dom. Scap. Lower Dyskineses: Kibler JSES ‘02 • I. Tilting of inferior angle (anterior tipping) • II. Internal rotation • III. Excessive elevation superior border (downward rotation) • Ellenbecker CORR ’11 Low reliability Scapular Dyskinesis Test • Visual observation of dynamic lifting of arm • Examiner visually determines whether dyskineses is present • Low to moderate reliability between examiners (.32-.57) • Mclure JATA 2009, Kibler BJSM 2013, Ellenbecker 2011 CORR • KT-1000 ACL tear measurement tool = .92 ICC between examiners. • Visual observation dyskineses is very subjective Scapular Assistance Test • Manually re- locate scapula • Reduction of painful arc symptoms • Non-specific Decreased Scapular Upward Rotation in Normal Pitchers • Laudner, Stanek, Meister, AJSM 2007 • Downward rotation in pitchers versus position players • Causes: increased ER,Laxity? – passive insuffiency Normal IGHL complex may elevate scapula when taught w ER • Causes: Muscular tightness – pect. Minor • Causes: Muscular fatigue • Tight post. Soft tissue = pulls scapula creating winging HS versus Collegiate Baseball Players • Div I throwers had increased protraction, downward rotation (posture) than HS Thomas JATA 2010 • Also increased GIRD, TRD • Measurements using digital inclinometer, and Kibler lateral slide • Test re-test reliability by same tester • Lateral slide not reproducible between examiners Ellenbecker CORR 2011 4

  5. 9/7/2018 Normal Preadolescent and Adolescent Hip and Scapula Coracoid Measurement • Beckett AJSM 2014 • Adolescents had positive scapular dyskinesis (y/n) 50% versus 26% • Poor SL squat (hip) both grps. 0, 13%, Adolescents increased hip ABD Str. • Skeletal maturation • Increased forward shoulder • May have increased risk • Increased distance from table • Tight Pec. Minor • Upward tilt Scapular Position in Throwing Versus Non-Throwing Athletes Posterior Shoulder Tightness Forward Scapular Posture • Myers AJSM 2005 Not measured while throwing • Throwing athletes showed increased retraction, elevation, internal rotation • No difference in a/p tipping • Nondominant limb not assessed • Throwing = different than control • Laudner AJSM 2010 • Posterior shoulder tightness = forward scapular position • Scapular pull Force Couples Scapula Scapulo-Humeral Relationship • 2 forces acting in opposite directions to produce rotation about an axis = upward rotation • S3 Spine,scapula stabilizing • Intelliskin • Upward arm movement: Ratio • 2:1 GH/ST = Overall • Popen & Walker JBJS • 1st 25 deg. Elev = 4:1 • Beyond 25 deg. = 5:4 • Dynamic 3# dumbbell lift, view lowering phase to assess 5

  6. 9/7/2018 Wall Push or Dumbbell Lowering • Maximum scapular winging occurs around 40 degrees of flexion • Greatest amount of winging during lowering phase • Paine 2009 “The Athlete’s Shoulder”, • Paine/Voight 2013 IJSPT • Dyskineses or Malposition Wall Push Isometric 45 degrees • Both “fingertips” pushing into wall • Observe unilateral backward winging: downward rotation, anterior tipping, internal rotation of scapula Muscle Functions Scapula Proximal Stability Promotes Distal Mobility • Rhomboids - provide retraction = brake of shoulder • Eccentric control of medial border during acceleration • Scapular Control allows NM switches to take over relaxed performance • Core stability shares load of UE Scapular Stability Swimmer Observe Hand Relaxation-Proximal Stability Distal Mobility Abnormal Muscle Function Rhomboids • Jobe JBJS ‘88 highest EMG of scapular muscles during follow through • Fatigue = unable to fully retract/cock • Scapular Axis in line with humeral axis • If not, stress to anterior capsular structures Muscle Functions Scapula • Rhomboids - provide retraction = brake of shoulder • Eccentric control of medial border during acceleration • Golfer: Trail Shoulder requires maximum scapular retraction plus eccentric control 6

  7. 9/7/2018 Scapular Strengthening Rhomboid/Serratus Kibler AJSM 2008 EMG Early Phase Exercises • Try single arm rowing isolated rhomboids • Trunk/Serratus row with metal bar • Robbery – scapular retraction move elbows toward back pockets • Lawnmower – Lower trap, Serratus Anterior Swiss Ball Robbery Muscle Function Serratus: • Protraction • Prevents winging • Cushions scapula • Shock absorption/ tether Strengthening Techniques • Rhomboids: Seated Rows, Cable Column Cocking, Manual Resisted Sideling • Dynamic Hug:Serratus, Subscapularis Sobush JOSPT Strengthening Techniques • Manual Resisted Techniques 7

  8. 9/7/2018 Body Blade Routine Cheerleader Super 6 Tubing Routine • 3x20 • Keep Elbows Straight • 2x per week • Allows most specific form of training to mimic throwing motion • 2 sets of 30 sec. each position Standing “snow angels” Strengthening Techniques: • On all fours: Wt. Bearing extremity is involved, resist flexion extension of NWB extremity to force scapular stabilization • Seated Pike, Prone scaption, lower trap. • Begin with no resistance, 3x20 • Working on scapular synchrony • Attempt to keep back of hand/forearms against wall • Progress to 2# cuff weights • Demanding routine Closed Chain Exercises Adjustable Cable Column • Allows adjustment for various positions • Lower trap strengthening, elbows down to back pockets • Be careful if you do it • Loads RC, not good for posterior instability • Load in Scapular Plane 8

  9. 9/7/2018 Advanced Closed Chain Routine – be aware of direction of applied external force • Bear crawl swiss ball • Standing plyoball stabs - Wilk MR Systems Scapular Training Summary Scapular Function • Scapular muscles help propel & position • Base of support = crucial to prevent injuries, improve performance • Look for shoulder soft tissue restrictions • Include scap in all shoulder rehabilitation & conditioning routines 9