Scapular Assessment and its implication on shoulder pain

The$scapula:$its$place$in$clinical$reasoning$in$ pa2ents$with$shoulder$pain$ Filip%Struyf,%PhD,%PT% % Scapular$assessment$and$its$place$in$clinical$ reasoning$in$pa2ents$with$shoulder$pain$ Why$should$we$adress$the$scapular?$ How$can$we$assess$scapular$movement?$ When$should$we$assess$scapular$movement?$ How$does$this$fit$within$clinical$reasoning?$ Why$did$hominins$evolve$the$ability$to$throw$at$high$speed?$$ $ +/$2$million$years$ago$in$Homo$erectus:$adapta2ons$in$features$that$$ enable$energy$storage$and$release$at$the$shoulder$?$ $ Hun2ng$ac2vi2es$intensified$around$this$2me$ $ Evolu2on$of$the$human$shoulder$$ is$the$reason$why$human$kind$survived$ $ Or$is$it$the$brain?$ 3$ A$brief$introduc2on...$ Proper2es$of$an$outcome$measure$ Consensus$on$terminology$ Proper2es$of$a$outcome$measures$ Reliable,$valid$&$responsive$ Some$say…$ $ (Ludewig et al., 2009) What$is$scapular$dyskinesis?$ “The$scapula$demonstrates$premature$or$excessive$ eleva2on$or$protrac2on,$nonsmooth$or$stuPering$ mo2on$during$arm$eleva2on$or$lowering,$or$rapid$ downward$rota2on$during$arm$ lowering”$(Dysrhythmia)$ “The$medial$border$and/or$inferior$angle$of$the$ scapula$are$posteriorly$displaced$away$from$the$ posterior$thorax.”$(Winging)$ (McClure et al. 2009) Scapular$assessment$and$its$place$in$clinical$ reasoning$in$pa2ents$with$shoulder$pain$ Why$should$we$adress$the$scapula?$ How$can$we$assess$scapular$movement?$ When$should$we$assess$scapular$movement?$ How$does$this$fit$within$clinical$reasoning?$ Is$scapular$dyskinesis$the$cause$or$effect$of$ shoulder$disorders?$ CAUSE%?% Does scapular positioning predict shoulder pain? (Struyf et al. IJSM 2013) Obvious scapular dyskinesis => higher probability of shoulder porblems in elite handball players (Clarsen et al. BJSM 2014) How$can$we$assess$scapular$movement?$ $ Factors$that$influence$scapular$posi2oning$ 18$ Visual%observaFon%of%scapular%posiFoning% $$ $$ McClure et al., 2009; Tate et al. 2009; Struyf, et al., 2009; Huang et al. 2015 a)$Normal%moFon:$no$evidence$of$abnormality$ b)$Subtle%abnormality:$mild$or$ques2onable$evidence$of$ abnormality,$not$consistently$present$ c)$Obvious%abnormality:$striking,$clearly$apparent$abnormality,$ evident$on$at$least$3/5$trials$ Ra2ng$scale$of$Mclure$et$al.$JAT$2009$ Loading$depends$on$bodyweight:$ <68$kg$=>$1.4$kg$load$ >68$kg$=>$2.3$kg$ Tate et al. 2009 Shoulder$protrac2on$(Baylor$square/acromion-table$ distance)$ Pectoralis$minor$muscle$length$ Scapular$upward$rota2on$ Scapular$asymmetry$ Clinical$measurements$ 23$ Acromion%–%table%distance% (Acromion-table distance (cm)/ BL (cm))*100 Reliable ! (ICC’s > 0.88) (Nijs et al., 2005; Struyf et al. 2009) Baylor$square$method$ Proc.$spinosa$C7$=>$$ Anterior$corner$acromion$ Reliable$&$valid$ $ $ $ $ (Peterson$et$al.,1997)$ AlternaFve%method%in%standing?$ Pectoralis%minor%muscle%length$ Inferomedial$aspect$of$ proc.$corracoid$ $è$inferolateral$aspect$of$ costosternal$junc2on$of$the$ 4th$rib$ Struyf et al., 2014 When$should$we$assess$scapular$movement?$ $ Is%the%scapula%related%to%the%paFents’% shoulder%pain?$ Is%the%scapula%related%to%the%paFents’% shoulder%pain?% Scapular$Assistance$Test$(SAT)$ Modified$Scapular$Assistance$Test$(mSAT)$ Scapular$Retrac2on$Test$(SRT)$ Scapular$Reposi2oning$Test$(SRT)$ $ Scapular%Assistance%Test% Scapular$Assistance$Test$ (m)SAT$ 34$ reliable (Seitz et al. 2012; Rabin et al., 2006) Scapular%reposiFoning%test% reposi2oning$test$$ $$(SRT)$ 35$ reliable Reduces pain and increase strength (Tate et al., 2008) How$does$this$fit$within$clinical$reasoning?$ $ At$this$point…$ Clinicians$can$use$reliable$(and$valid)$clinical$ tests$for$the$assessment$of$both$sta2c$and$ dynamic$scapular$posi2oning$in$pa2ents$with$ shoulder$pain.$$ No$causal$associa2on$with$shoulder$pain$ proven$ Benefit$of$symptom$altera2on$tests$ Scapular$dyskinesis$≠$diagnosis$ is$a$clear$example$of$an$assessment$strategy$ that$emphasizes$the$search$for$dysfunc2ons$ Scapular$dyskinesis$ prognoses$of$shoulder$pain$is$nega2vely$ altered$by$more$then$movement$impairment$ or$pain$severity$alone.$$ Clinical$reasoning:$factor$analysis$ of…$ Psychosocial$ Neurophysiological$ Lifestyle$ Movement$related$impairments$ DO$NOT$PATHOLOGIZE$YOUR$PATIENT$ PROFILE$YOUR$PATIENT$ What$about$the$SICK$scapula$syndrome?$$ $ Scapular$malposi2on$ Inferior$medial$border$prominence$ Coracoid$pain$ Kinesis$abnormaili2es$of$the$scapula$