Lecture Scap Malaga 2

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)

Why should we adress the scapula?
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)
shoulder disorders?
EFFECT ?
pain-dependent
inhibitory input

(both ipsilateral and contralateral)
Hodges et al. 2013; Hodges and Tucker

2011a; Nijs et al. 2012b; Farina et al. 2001;
La Pera 2001; Valeriani et al. 1999
shoulder disorders?
CAUSE ? NO EFFECT?
YES
Risk of transi2on to chronic?
Assessment &
Therapy
Assessment &
Therapy
Studies that differen2ate have larger
succes rates!
  “scapular muscle rehabilita2on improves pain
and func2on (SPADI) in pa2ents with mild
impingement symptoms” (6 weeks training)”
De Mey et al. Am J Sports Med 2012
  “A large clinically important treatment effect
in favor of scapular motor control training was
found in self-reported disability”
Struyf et al. Clin Rheum 2013

Clinical outcomes of a scapular-focused treatment in par2cipants with shoulder injury:
a systema2c review
(BJSM in review)
Elja AE Reijneveld1, Suzie Noten2, Lori A Michener3, Ann Cools4, Filip Struyf2
  6 studies included (>6/10 PEDRO score)

scapular-focused exercise therapy
scapular mobiliza2on
scapular taping
RESULTS?
  Moderate evidence = scapular-focused treatment
compared to other physiotherapeu2c treatment is
effec2ve to improve scapular muscle strength in
par2cipants with subacromial impingement
syndrome.
  Conflic2ng evidence was found for improvements in
pain, func2on and clinical measures of scapular
posi2oning.
  No evidence was found for improvements in shoulder
range of mo2on, rotator cuff muscle strength and
quality of life.
Why should we assess scapular movement?

Factors that influence scapular posi2oning
Visual observaFon of scapular posiFoning

McClure et al., 2009; Tate et al. 2009; Struyf, et al., 2009; Huang et al. 2015
18
Ra2ng scale of Mclure et al. JAT 2009
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
Loading depends on bodyweight:
<68 kg => 1.4 kg load
>68 kg => 2.3 kg
Tate et al. 2009

Clinical measurements
  Shoulder protrac2on (Baylor square/acromion-table
distance)
  Pectoralis minor muscle length
  Scapular upward rota2on
  Scapular asymmetry
Acromion – table distance
(Acromion-table distance
(cm)/ BL (cm))*100
Reliable ! (ICC’s > 0.88)
(Nijs et al., 2005; Struyf et al. 2009)

23
AlternaFve method in standing?
  Baylor square method

  Proc. spinosa C7 =>
Anterior corner acromion
  Reliable & valid

(Peterson et al.,1997)
Pectoralis minor muscle length
Inferomedial aspect of
proc. corracoid
è inferolateral aspect of
costosternal junc2on of the
4th rib
Struyf et al., 2014

Pectoralis minor index
PMI=
Pectoralis Minor length (cm) /BL (cm)) x 100
Reliable (intrarater)
Valid? (Yes to cadaveric studies)

Caliper!!
Struyf et al., 2014

26
Scapular upward rotaFon
Gravity or digital inclinometers

At rest, 45°, 90°, 135° & endrange
Reliable (intra)
Valid (digital)
(Watson et al., 2005; Johnson et al. 2001)

27
Scapular asymmetry
Distance medial border scapula => proc. Spin. Th4
or Th3
Reliable & Valid
(Peterson et al. 1997, Nijs et al. 2005)

Scapular asymmetry
  “ scapular distance”
  Distance angulus acromialis to
Th3
  Divided by the length of the spina
scapulae
  Reliable
Scapular asymmetry
Lateral scapular slide test
(Koslow et al. 2003; Nijs et al. 2005)

In summary
Observa2onal evalua2on systems and
assessment of scapular upward rota2on seem
suitably evidence-based for clinical use.

Do not use it as a physical examina2on test for
diagnosing pathologies of the shoulder.

Asymmetry is ok!
Larsen et al. 2015; Wright et al. 2013; Morais et al. 2013


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
reliable
(Seitz et al. 2012; Rabin et al., 2006)

34
Scapular reposiFoning test
  reposi2oning test
(SRT)
reliable
Reduces pain and increase strength
(Tate et al., 2008)

35

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
Should we use an algorithm?
  easy to follow
  and have the inten2on to eliminate
unconscious mistakes
  excellent way to structure and visualize clinical
reasoning processes
  “easy to follow” = rela2vely simple
  A shoulder pain pa2ents ≠ simple
  it would be easier to use reason to solve the
problem.
What if the pa2ent’s shoulder problem falls
outside of the reasoning of the algorithm?
= > it will not be fixed

In summary
  use a pa2ent-centered approach, profiling the
pa2ents’ psychosocial-, neurophysiological-,
and lifestyle factors and movement
impairments that inform our clinical decision-
making.
Stop pathologizing, start profiling!

THANKS !
[email protected]
@FilipStruyf

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The

scapula: its place in clinical reasoning in

Proper2es of an outcome measure

Reliable, valid & responsive

(McClure et al. 2009)

Obvious scapular dyskinesis =>

Hodges et al. 2013; Hodges and Tucker

Risk of transi2on to chronic?

6 studies included (>6/10 PEDRO score)

a) Normal moFon: no evidence of abnormality

Tate et al. 2009

Reliable ! (ICC’s > 0.88)

(Nijs et al., 2005; Struyf et al. 2009)

Baylor square method

Struyf et al., 2014

Struyf et al., 2014

Gravity or digital inclinometers

(Watson et al., 2005; Johnson et al. 2001)

Reliable & Valid

(Peterson et al. 1997, Nijs et al. 2005)

(Koslow et al. 2003; Nijs et al. 2005)

Larsen et al. 2015; Wright et al. 2013; Morais et al. 2013

Scapular Assistance Test (SAT)

Scapular Assistance Test

(Seitz et al. 2012; Rabin et al., 2006)

(Tate et al., 2008)

Movement related impairments

DO NOT PATHOLOGIZE YOUR PATIENT

it would be easier to use reason to solve the

= > it will not be ﬁxed

Stop pathologizing, start proﬁling!

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  6 studies included (>6/10 PEDRO score)

  Baylor square method

  it would be easier to use reason to solve the