Summary Sheet for Diagnosis and Treatment Shoulder Movement System Impairment Syndromes Developed by: Cheryl Caldwell, PT, DPT, CHT and Renee Ivens, PT, DPT October 2014 Scapular Diagnosis Scapular Internal rotation • anterior tilt • insufficient upward rotation • abduction The primary movement impairment is excessive scapular internal rotation which often occurs with scapular anterior tilt, abduction, and insufficient upward rotation either individually or combined. The movement impairment may be identified either at the end range due to stiffness or dynamically during arm elevation or lowering. Resting scapular alignment is usually in excessive internal rotation and anterior tilt. The serratus anterior may not perform optimally but major strength loss is not the primary problem. Criteria for Normal Motion External Rotation and Posterior Tilt At end range of arm elevation, the scapular orientation should be: • 10°-20° anterior to the frontal plane (vertical axis thru ACJ) • at least 10° of posterior tilt (axis parallel to scapular spine at ACJ). Primary Movement Impairments Main Focus of Treatment Anterior Tilt Anterior Tilt During the Motion what do you see? • Increase stiffness of • Excessive scapular IR and anterior posterior axioscapular tilt muscles • May see tilt earlier in the range o Improve activation and hypertrophy What do you see at end range? • Stretch • Excessive scapular IR o SH muscles while • May not see anterior tilt maintaining scapular position o Pectoralis minor • Dissociate GH from ST motion o Letting go with SH muscles Upward Rotation Vertebral border of the scapula achieves 60° + 5° of upward rotation with arm fully elevated Insufficient Upward Rotation During the Motion what do you see? • scapula downwardly rotates when a load is placed on the arm or during arm rotation • scapula fails to UR sufficiently during arm elevation What do you see at end range arm elevation? • Scapula UR < 60° +5 With Insufficient upward rotation • Improve the performance of serratus anterior and the trapezius mm while trying to restore normal scapular UR without excessive IR. Summary Sheet for Diagnosis and Treatment Shoulder Movement System Impairment Syndromes Developed by: Cheryl Caldwell, PT, DPT, CHT and Renee Ivens, PT, DPT October 2014 Scapular Diagnosis Criteria for Normal Motion Abduction/Adduction The scapula remains approximately 3” from spine during motion The clavicle should retract 16° during shoulder flexion. Primary Movement Impairments With Abduction During the Motion what do you see? • greater than ½” (1 cm) of abduction of scapula in first 90° of shoulder flexion • scapula rests in abduction and remains abducted during shoulder flexion What do you see at end range arm elevation? root of spine of scapula > or = 3.5 inches (9 cm) from vertebral spine Scapular Depression The primary movement impairment in this syndrome is insufficient scapular elevation usually with insufficient scapular UR. The movement impairment may be seen at any point in the range of arm elevation or on the return. Resting scapular alignment may be depressed, downwardly rotated or normal. The primary problem may be poor muscle performance of the upper trapezius or inappropriate activation and/or increased stiffness of the depressors and downward rotators. Scapular Elevation During the motion what do you see? • At end range arm elevation, the • acromion drops during the first acromion is level with C6-7. 90° of arm elevation or during • Clavicle should elevate at least arm rotation 6-10° • scapula depresses when a load is placed on arm What do you see at end range arm elevation? • acromion is below C6-7 at end range arm elevation Main Focus of Treatment With Abduction • Focus on avoiding excessive scapular abduction/IR during arm motions • Increase stiffness of middle trapezius posterior axioscapular muscles o Improve activation and hypertrophy • Stretch o SH muscles and posterior GHJ capsule while maintaining scapular position • Active elevation of the scapula (acromion) especially during the last 1/2 of the ROM of arm elevation • Arm support with correct scapular alignment • Increase stiffness and performance impairments of the upper and middle trapezius Summary Sheet for Diagnosis and Treatment Shoulder Movement System Impairment Syndromes Developed by: Cheryl Caldwell, PT, DPT, CHT and Renee Ivens, PT, DPT October 2014 Scapular Diagnosis Scapular External rotation/adduction syndrome The primary movement impairment in this syndrome is insufficient scapular abduction and internal rotation usually resulting in insufficient scapular upward rotation. A key contributing factor to this syndrome is the excessive activation of the scapular external rotators and adductors resulting in an alignment of scapular external rotation/adduction and preventing normal scapular movement during arm elevation. Scapular Winging (Pathological – AC Joint) The primary movement impairment is scapular winging during shoulder flexion and extension most commonly due to profound weakness of the serratus anterior but weakness of the trapezius may also be a cause. Criteria for Normal Motion External Rotation, Abduction, and Upward Rotation At end range of shoulder flexion, the scapular orientation should be: • 10°-20° anterior to the frontal plane (vertical axis thru ACJ) • Vertebral border of the scapula achieves 60° + 5° of upward rotation with arm fully elevated The scapula remains approximately 3” from spine during motion The vertebral border of the scapula is in contact with the thorax during resting alignment and motion. Primary Movement Impairments During the motion what do you see? • During the middle to late range of arm elevation the scapula remains externally rotated and adducted with decreased UR. What do you see at end range arm elevation? • Root of spine of scapula < or = 2.5 inches (6.5 cm) from vertebral spine • Scapula ER <10-20° anterior to frontal plane • Scapula UR < 60° +5 During the motion what do you see? • vertebral border protrudes from thorax during arm elevation and lowering (serratus anterior < 3/5) • scapular winging during shoulder rotation, lifting, or weight bearing on the upper extremity. What do you see at end range arm elevation? • Limited range of arm elevation Main Focus of Treatment • Focus on increasing scapular abduction, IR, and UR during arm motions • Improve the performance of the serratus anterior • Increase the extensibility and decrease activation of the rhomboids and middle trapezius. • The thoracic spinal curve is often flat therefore encourage slight thoracic flexion. If serratus anterior muscle strength is 0 to 2/5, focus of treatment is compensatory. • Education regarding how to avoid injury to the glenohumeral joint, cervical spine and further insult to the long thoracic nerve. o Arm support o Avoid repetitive overhead activities and lifting • Improve performance of trapezius, especially upper, to compensate Summary Sheet for Diagnosis and Treatment Shoulder Movement System Impairment Syndromes Developed by: Cheryl Caldwell, PT, DPT, CHT and Renee Ivens, PT, DPT October 2014 Scapular Diagnosis Criteria for Normal Motion Scapular Elevation (SC) Scapular Elevation During the motion what do you see? • At end range arm elevation, the • Scapula elevates excessively acromion is level with C6-7. starting early in the motion • Clavicle should elevate at least 6-10° What do you see at end range arm elevation? • acromion is above C5-6 level • limited GHJ ROM The primary movement impairment in this syndrome is excessive scapular elevation. The movement impairment is usually identified early in the range and continues throughout arm elevation. For most patients the primary problem is limited glenohumeral motion and not poor muscle performance. Primary Movement Impairments Main Focus of Treatment If the serratus anterior muscle function is returning, the focus is on appropriate activation of the involved muscle both concentrically and eccentrically. • Particular attention should be paid to the quality of scapular motion which initially requires exercising in gravity lessened positions. • If GH hypomobility is present, focus of treatment is to increase GH mobility. • If rotator cuff function is deficient then scapular elevation as a compensatory technique may be necessary. • Increase activation, strength of scapular depressors • Decrease activation and increase length of scapular elevators Summary Sheet for Diagnosis and Treatment Shoulder Movement System Impairment Syndromes Developed by: Cheryl Caldwell, PT, DPT, CHT and Renee Ivens, PT, DPT October 2014 Humeral Diagnosis Anterior Glide Superior Glide Criteria for Normal Motion • Humeral head remains centered on the glenoid • During flexion, the humeral head spins around a relatively fixed axis. • During arm abduction the humeral head superior translation is offset by inferior gliding. • During humeral rotation the rolling and gliding of the humeral head offset each other so that humeral head remains centered. • During glenohumeral laterally rotates (LR) the humerus should spin on axis without horizontal abduction Primary Movement Impairments During the motion or at end range what do you see? • Excessive movement or alignment of humeral head anteriorly o Shoulder abduction o Standing GH LR GH extension o Supine MR o Prone active LR horizontal abduction • Increased range of GH LR • Excessive movement of humeral head inferiorly at the end range of arm elevation noted as prominence of the humeral head in the axilla • Most often associated with scapular internal rotation Main Focus of Treatment • Train for precise movement before strengthening. • Avoid moving the elbow posterior to the frontal plane. • Improve the performance of the subscapularis. • Increase the flexibility of the posterior structures of the shoulder if needed. • Decrease the activation of the posterior deltoid • Normalize scapular alignment and movement to decrease stresses on the GHJ. During the motion or at end range what do you see? • Excessive movement of humeral head superiorly o Increased prominence of humeral head distal to acromion o Shallow skin creases at lateral edge of acromion • • Improve the performance of the rotator cuff muscles while minimizing the activity of the deltoid. Normalize length of capsule and scapulohumeral muscles. Summary Sheet for Diagnosis and Treatment Shoulder Movement System Impairment Syndromes Developed by: Cheryl Caldwell, PT, DPT, CHT and Renee Ivens, PT, DPT October 2014 Humeral Diagnosis Criteria for Normal Motion Glenohumeral Multidirectional Hypermobility Glenohumeral Medial Rotation Primary Movement Impairments • Humeral long axis compression into glenoid during GH rotation During the motion or at end range what do you see? • Humeral head glides excessively with arm elevated in more than one direction o Excessive physiological ROM in multiple directions • Most often associated with insufficient scapular motion Humerus should LR during arm elevation, more during abduction than flexion (approximately 60°). During the motion or at end range what do you see? • Insufficient GH LR during shoulder flexion or abduction • During passive length tests humerus difficult to maintain GH LR Main Focus of Treatment • Normalize scapular alignment and movement • Maximize scapular motion during arm elevation to decrease the stresses on the GHJ • Improve the performance and hypertrophy the rotator cuff muscles emphasizing precise motion • Avoid end range GHJ movements • • • GH Hypomobility Full physiological ROM in all directions At end range what do you see? • Limited physiological and accessory motion in all directions During arm elevation what do you see? • Humeral superior glide • • Train corrected movement pattern across a variety of movements. Improve the performance of the shoulder LR muscles Improve the flexibility of the shoulder MR muscles. Improve GHJ passive and active ROM with attention to precise movement. Increase the flexibility of the capsule and rotator Summary Sheet for Diagnosis and Treatment Shoulder Movement System Impairment Syndromes Developed by: Cheryl Caldwell, PT, DPT, CHT and Renee Ivens, PT, DPT October 2014 Humeral Diagnosis Criteria for Normal Motion Primary Movement Impairments Main Focus of Treatment cuff. • Improve the strength of the rotator cuff muscles Factors to Consider When Determining the Movement Diagnosis If More Than One Movement Impairment Is Present • The movement impairment that, when corrected, best alleviates the symptoms, determines the diagnosis • Where in the range of motion the symptoms occur & which movement impairment is the most obvious at that range • The frequency of each impairment during the exam o although greater weight is given to the standing tests, if an impairment is noted frequently during the other test positions, that information may be helpful in assigning the diagnosis. • One movement impairment appears to be more significant than others • The ease of movement or alignment modification o If modification in 1 direction is accomplished easily but difficult in another direction, often the direction that was most difficult to modify will become the diagnosis o The patient may need to replicate the activity in which symptoms are produced Humeral Diagnostic rules: • If glenohumeral hypomobility exists it supersedes all other diagnoses. • Accessory joint conditions take precedence over glenohumeral medial rotation impairment. • If shoulder MR and superior glide co-exist, assign superior glide as the diagnosis. • If anterior glide and superior glide co-exist, the anterior glide is usually considered the diagnosis.
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