Purpose of this

presentation

Normal biomechanics scapular
Scapulothoracic mechanisms: muscles and muscle recruitment
patterns
Neurophysiology and control
Scapular muscle dysfunction in
of scapular movement shoulder pathology

Rehabilitation exercises: activity
patterns
Prof dr Ann Cools, PT, PhD
Dept Rehab. Sciences & Physiotherapy
Ghent University, Belgium BESS Instructional Course 2009

Gent-Belgium-2009

Shoulder kinematics: Shoulder kinematics:

Importance of muscle action Importance of muscle action

Role of the physiotherapist:
physiotherapist:

Role of the static stabilizers?
stabilizers?
Muscle function can be changed by
Limited static articular constraints in
preventive of rehabilitation exercises
glenohumeral and scapulothoracic joint

BESS Instructional Course 2009 BESS Instructional Course 2009

Force-
Force-couples Scapulothoracic force couples

Muscles with
UT + SA:
different/opposite
action

Working together MOVEMENT

Specific action

Functional
stability and LT:
performance

MOVEMENT
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REGULATION
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(Johnson Clin Biomech 1994) (Johnson Clin Biomech 1994)

Upper trapezius
Upward rotation +
Lower trapezius
elevation Scapular upward

Serratus Anterior rotation in end-
end-
Upward rotation + range elevation of
protraction the shoulder

Lower trapezius
Stability and
movement control

BESS Instructional Course 2009 BESS Instructional Course 2009

Scapular muscle dysfunction
in relation to shoulder pain
(impingement)
Doctoral Project 2003
Ann Cools - UGent
Dept. Rehabilitation Sciences
& Physiotherapy
Scapular Muscle
Recruitment?

Muscle STRENGTH
– Isokinetic muscle Peak Force, Power & Fatigue

Muscle BALANCE
– Strength ratio agonist/antagonist
– EMG during isokinetic movements

Muscle TIMING
– EMG latency times during scapular (protraction-
(protraction-
retraction) and glenohumeral (abduction &
external rotation) movements
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Strength Deficit Strength Deficit

METHODS:
METHODS: RESULTS (N=19, N=30):

Isokinetic assessment

Decreased muscle strength in
of scapular muscle strength
serratus anterior

protraction-
protraction-retraction
movements
Compared to non-
non-injured side &
in the scapular plane healthy control group
A. Cools, E. Witvrouw, G. Declercq et al. 2004, Br J Sports Med
A. Cools, E. Witvrouw, G. Declercq et al. 2005, J Athl Train
A. Cools, E. Witvrouw, G. Declercq et al. 2002, Iso Exc Sci
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 Muscle Imbalances during
Muscle imbalances
scapular movements
METHODS:
METHODS:
RESULTS Protraction-
Protraction-retraction
(N=19):

Agonist/antagonist
Agonist/antagonist ratio
(protraction/
protraction/retraction)
retraction)
Decreased ratio protraction/
protraction/retraction

Surface EMG scapular muscles
Decreased lower trapezius activity
during isokinetic assessment during retraction

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A. Cools, E. Witvrouw, G. Declercq et al. 2004, Br J Sports Med

Muscle Imbalances during

shoulder movements Muscle Latency Times
RESULTS external rotation – METHODS:
METHODS:
abduction (N=39):

Sudden
perturbation

Increased upper trapezius activity
Surface EMG:
EMG:

Decreased lower-
lower-middle trapezius muscle onset
activity

BESS Instructional Course 2009 BESS Instructional Course 2009

A. Cools, E. Witvrouw, G. Declercq et al. 2006, Scand J Med Sci Sports
A. Cools, E. Witvrouw, G. Declercq et al. 2002, JOSPT

Muscle Latency Times

References:
References:
RESULTS (N=39): – Cools et al. 2002, JOSPT,
JOSPT, 32(5):221-
32(5):221-229
– Cools et al. 2002, Iso Exc Sci,
Sci, 10(3): 129-
129-136
– Cools et al. 2003, Am J Sports Med, 31(4), 542-
542-549
– Cools et al. 2004, Br J Sports Med, 38:64-
38:64-68
– Cools et al. 2005, J Athl Training, 40(2): 104-
104-110

Delayed onset lower trapezius – Cools & Walravens: Oefentherapie bij schouderaandoeningen,
Standaard Uitgeverij, 2007

Bilateral disorders – Cools et al. 2007, Scand J Med Sci Sports,
Sports, 17(1): 25-
25-35
– Cools et al. 2007, Am J Sports Med, 35(10):1744-
35(10):1744-1751

Abnormal recruitment pattern – Cools et al. 2007, J Athl Training,42(4):458–463
Training,
– Cools et al. 2008, BJSM, 42(8), 628-
628-635
– Cools et al. 2008, BJSM, 42(3):165-
42(3):165-71
– De Mey et al. 2009, JOSTP, in press
– Maenhout et al. 2009, BJSM, submitted June 2009
– Cools et al. 2009, paper in progress, to be submitted to SJMSS

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A. Cools, E. Witvrouw, G. Declercq et al. 2003, Am J Sports Med

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 CAUSE - CONSEQUENCE
RELATIONSHIP
- Cause – consequence?
- Relevance of treatment?
- Detection in clinical practice?
- Which exercises?
- Guarantee for pain and symptom relief?
- extrapolation of results to functional
overhead activities?
(Scapula Summit, Lexington USA, 2003: B. Kibler, E.
Witvrouw, A. Cools, P. Ludewig, P. Mc Clure, M. Kelley, P.
Donley, M. Schwellnus, T. Uhl)
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CAUSE - CONSEQUENCE RELATIONSHIP:

RELATIONSHIP: CAUSE - CONSEQUENCE RELATIONSHIP:
RELATIONSHIP:
“Secondary phenomenon based on “Primary cause of shoulder pain
muscle inhibition as result of pain”
pain” and impingement symptoms”
symptoms”

Reflexive muscle inhibition known
Scapular dyskinesis tends to narrow
phenomenon subacromial space (Ludewig 2000, Lukasiewicz
1999)

Aspecific scapular dyskinesis,

Bilateral scapulothoracic
no direct correlation with
dysfunction (Cools 2003)
shoulder pathology
(scapula summit 2003)

BESS Instructional Course 2009 BESS Instructional Course 2009

Preliminary conclusion:
conclusion:

Primary predisposition,
predisposition, - Cause – consequence?
aggravated by pain - Relevance of treatment?
inhibition mechanisms - Detection in clinical practice?
- Which exercises?
- Guarantee for pain and symptom relief?
- extrapolation of results to functional
overhead activities?

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 Scapular involvement in
shoulder pain?
Scapular Assistance Scapular Retraction - Cause – consequence?
Test Test - Relevance of treatment?
- Detection in clinical practice?
- Which exercises?
- Guarantee for pain and symptom relief?
- extrapolation of results to functional
overhead activities?

(Kibler AJSM 2006, Rabin JOSPT 2006,

BESSTate JOSPT
Instructional Course 2008)
2009 BESS Instructional Course 2009

Classification of scapular
dyskinesis (Kibler JSES 2002) TYPE I

Type I:
– prominent inferior angle
scapula
– anteriorly tilted scapula

BESS Instructional Course 2009 BESS Instructional Course 2009

Classification of scapular
Type I scapular dyskinesia
dyskinesis (Kibler JSES 2002)

Type II:
– prominent medial border scapula
– internally rotated scapula
– “winging”
winging”

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 TYPE II

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Classification of scapular
dyskinesis (Kibler JSES 2002) TYPE III

Type III:
– prominent superior/medial
superior/medial
border scapula
– downward rotated scapula
– “shrug”
shrug” with elevation

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However: scapular dyskinesia is

difficult to classify!!

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 BESS Instructional Course 2009 BESS Instructional Course 2009

Scapular Rehab Algorithm

Lack of Lack of
Soft-tissue flexibility Muscle performance

- Cause – consequence? Scapular muscles GH muscles/capsule Muscle Control Muscle Strength

- Relevance of treatment?
- Levator scapulae - infraspinatus - co-contraction - lower/middle trap
- Detection in clinical practice? - pectoralis minor - posterior capsule - force couples - serratus anterior

- Which exercises?
- Guarantee for pain and symptom relief? STRETCHING & MOBILISATION
NEUROMUSCULAR
COORDINATION
STRENGTH
TRAINING

- extrapolation of results to functional

overhead activities? Conscious muscle
control
Conscious muscle
control

- Manual stretching
- home stretching Advanced control
Balance -ratio
- soft tissue techniques During basic activities
- manual mobilisations
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Advanced control
Endurance/strength
During sports movements

Conscious muscle control lower Conscious muscle control lower

trapezius:
trapezius: Scapular Orientation trapezius:
trapezius: Scapular Orientation
Exercise Exercise

Angulus inferior
Subjects are able to perform consistent

Sternum movements of the scapula into posterior tilt

Proc coracoideus and upward rotation
(Mottram 1997,2003,2009
Significant increase scapular muscle activity
Cools 2008) (however also upper trap)

High correlation between
assisted and unassisted
exercise
(Mottram 2009)
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Rehabilitation muscle Exercises to improve
balance UT/LT & UT/MT timing of muscle activity?
activity?

Exercises with low UT/LT & UT/MT EMG analysis of muscle onset of UT, MT, and LT (in relation to
posterior deltoid)
deltoid) in previously selected selected exercises
ratio (n=30)
(N=45)(Cools et al. AJSM 2007)

MT LT UT

Deltoid actvity
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Integration Kinetic Chain into

open chain shoulder
rehabilitation exercises
6 modalities for 4 shoulder rehabilitation
exercises (N=41)
(Cools et al. 2007, unpublished data Master Thesis Sohier et al.)

(De Mey & Cools, in press, JOSPT 2009)

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Integration Kinetic Chain into

Results:
Results: muscle balance ratios closed chain shoulder
UT/LT and UT/MT rehabilitation exercises

Unilateral performance superior to bilateral
6 modalities of the push-
push-up plus exercise (N=32)

Sitting position superior to standing

Stance on one leg = stance on two legs

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(Cools et al. 2007, unpublished data Master Thesis Sohier et al.)

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 Results:
Results: EMG-
EMG-activity and muscle Results:
Results: EMG-
EMG-activity and muscle
balance ratios balance ratios

Highest SA activity (44%MVC) en best
Lowest UT activity (13%MVC) in push-
push-up
UT/SA ratio (0.40) when ipsilateral leg is both legs support
extended

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(Maenhout & Cools, submitted BJSM 2009) (Maenhout & Cools, submitted BJSM 2009)

Results:
Results: EMG-
EMG-activity and muscle Conclusion
balance ratios

In general low activity of MT & LT, except
Scapular muscle function: FORCE
when heterolateral leg is extended
COUPLES
(LT=20%MVC)

Try to identify SPECIFIC movement
disorders and possible underlying
mechanisms

Muscle BALANCE and proper TIMING
are important issues in rehabilitation

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(Maenhout & Cools, submitted BJSM 2009)

Thank you!

BESS Instructional Course 2009

(Gent – Belgium)