scapular function and dysfunction - filestack
TRANSCRIPT
Scapular function and dysfunction
- Impingement- Muscle detachment
W. Ben Kibler, MD
Medical director
FUNCTION
IMPINGEMENT REVISITED
• Is “impingement” always a diagnosis- isolated description of pathology to base treatment upon- or more likely a syndrome-multiple causative factors
WHAT IS IT• Dr Charles Neer- JBJS 1972• Rotator cuff under acromion,
coraco-acromial arch• Subacromial alteration• Abrasive wear- stages 1,2,3• Anterior acromioplasty
EVALUATION• Exam-find the impingement
positions- painful arc– Neer, Hawkins maneuvers
• Test- eliminate sx- injection• X-ray- anatomy- outlet view• “Diagnosis”- impingement
TREATMENT• Follows exam and tests that
make the “diagnosis”• Numb up the space• Address acromion/C-A arch-
increase subacromial space• “Raise the roof”• Open vs arthroscopic
TREATMENT• Non operative
– Modalities– Rotator cuff based exercises to address demonstrated weakness
– Mobilization- stiffness
TREATMENT• Operative
– SAD, +/- DCE– Another DCE– Other scope- labral, capsular release
• Pain clinic
OUTCOMES• Very variable• Generally good- early
symptom relief• Later failures- return of sx• Not as good for young
throwers, workers- 47--77%
OUTCOMES• JBJS(Br)- 2009
– Outcomes from surgery or rehabilitation are the same
– More cost for surgery– “Natural history not well understood”
IMPINGEMENT • Frequently is an alteration
of normal coupled scapulohumeral rhythm, creating pressure/tension in a confined changeable space with many pain receptors
IMPINGEMENT• Broader perspective- factors
causative for “impingement”• Dx “impingement”- start of
the process, not the end• Appropriate treatment based
on all factors in diagnosis
Scapula/impingement• BJSM 2013 Scapular Summit• “Substantial frequent
involvement in symptoms”• ? Cause or effect• Altered acromion, sub
acromial space, strength
IMPINGEMENT • 3-D kinematic
analysis–Decreased
posterior tilting significantly (~10°)
– Lukasiewicz et al. JOSPT 1999
– Ludewig & Cook PT 2000
DYSFUNCTION
DYSFUNCTION
EVALUATION• Scapular exam
– Clinical observation– Position– Motion- arm motion– Corrective maneuvers
EVALUATION• Corrective
maneuvers– Scapular
Assistance Test
• Assist scapular upward rotation/posterior tilt
• (+)- Relief of external impingement symptoms
– Kibler,W.B. AJSM 26(2):325-337, 1998
– Rabin, A. et al, JOSPT 36(9): 653-660, 2006
SAT Results: Posterior Tilt
-20
-15
-10
-5
0
5
10
15
20
30 60 90 120
Post
erio
r Tilt
(Deg
rees
)
Unassisted SAT
Main Effect:SAT (5°) > Unassisted (-2°)p =.007
EVALUATION• Corrective
maneuvers– Scapular
Retraction Test
• Assist scapular external rotation/posterior tilt
• (+)- Inc rot cuff strength, relief- internal impingement
– Kibler WB, AJSM 1998– Kibler WB, Sciascia AD, Dome
DC, American Journal of Sports Medicine, 34(10): 1643-1647, 2006
Muscle detachment• Scapular emphasis• MD- previous surgery inc sx• “I know something’s not
attached- find out what”• Surgical exploration- tear• ? How to fix
Muscle detachment• More cases over years• How to clinically categorize
the symptoms, clinical picture, treatment
• Surgical treatments• What are the outcomes
Clinical Results from Kibler et al JSES 2014
Prospective studyInjury mechanism Number (%)MVA 35 (45)Traction/load 19 (24)Athletics 15 (19)Other 9 (12)
Prospective study• Patient reported complaints
– Localized medial border scapular pain- 78 (100%)
– Decreased overhead activity capability- 77 (99)
– Decreased forward flexion capability- 76 (97)
Prospective study• Patient reported complaints
– Headaches/muscle spasms- 67 (86)
– Decreased flexion strength- 52 (67)
– Decreased abduction/over head strength- 46 (59)
Prospective study• Sx duration 51(1.5- 372) mos• 4 (1- 20) other physicians• 1 (0-6) other surgeries• PT 14 (1- 42) mos• 3 (2 CT, 1 MRI) imaging
positive for muscular injury
Prospective study• Physical exam findings
– Dyskinesis- 78 (100)– Medial border pain- 76 (97)– (+) SRT- 76 (97)– (+) SAT- 76 (97)
Prospective study • Physical exam findings
– Can’t raise > 90- 75 (96)– Weak rotator cuff- 59 (76)– Palpable defect- 47 (60)– (+) impingement- 40 (51)
Prospective study• Surgical findings
– Low trap- 78 (100)– Rhomboids- 78 (100)– Increased scar- 16 (20)– Serratus- 4 (5)
Foot Head
Medial Scapular Border
Infraspinatus MuscleScapular Spine
Lower Trapezius
Muscle
Detachment
Prospective studyASES scores (N= 78)
Intake/DischargePain 18/35 P<.0001Function 20/28 P<.0001Total 38/63 P<.0001
Prospective study2- 3 year ASES scores (N=34)
Intake/Discharge/Follow upPain 20/34/35 P<.0001Function 19/30/34 P<.0001Total 39/63/69 P<.0001
Conclusions• Specific clinical syndrome• Major activity/life disruption• Consistent history, physical
exam, sx, dysfunction• Imaging not helpful• Consistent surgical findings
Conclusions• More awareness• Need to recognize the acute
injury and start definitive treatment so that the long term problems don’t get established
THANK YOU