Scapular Abduction

The primary movement impairment in this syndrome is excessive scapular abduction.  Muscle impairments are a dominance of scapular abductor muscles (pec major, serratus anterior) and insufficient activity of the scapular adductor (primarily trapezius) muscles, primarily their alignment and appearance. (Sahrmann, 2002)

SYMPTOMS & HISTORY

ASSOCIATED WITH IMPINGEMENT

  • Pain in ant/post shoulder or deltoid area
  • May experience pain w/overhead activities or reaching forward
  • Unable to sleep on affected side
  • May be assoc w/thoracic or cervical pain

ASSOCIATED WITH ADDUCTOR STRAIN

  • Pain between scapula and spine or along vertebral border of scapula

ASSOCIATED WITH TOS

  • May experience numbness and tingling in hand
  • May experience decreased circulation or feeling of coldness or whole arm falling asleep with arms overhead
  • Pain in interscapular area, medial arm, forearm, and hand

ASSOCIATED WITH INSTABILITY

  • Clunking w/arm movementsor the sensation of the shoulder slipping out of socket

ACTIVITIES

  • Weight lifters or heavy laborers
  • Cellist
  • Hairdressers
  • Swimmers

KEY TESTS & SIGNS

ALIGNMENT AND APPEARANCE

  • Vertebral border of scapula greater than 3 inches from spine
  • Plane of scapula is greater than 30 degrees anterior to frontal plane
  • Correction of alignment deficiency decreases symptoms; if assco w/ tos distal symptoms may increase w/correction of scapular impairment

MOVEMENT IMPAIRMENTS

  • Shoulder flexion:  excessive shoulder abduction; correction of abduction decreases symptoms
  • Shoulder flexion:  axillary border of scapula protrudes 1/2 inch or more beyond posterior lateral border of thorax with arm overhead
  • Scapula and humerus move in 1:1 ratio
  • Insufficient scapular adduction during gh horizontal abduction

LIFTING/HOLDING

  • Unable to maintain proper scapular alignment (scap abducts) during lifting or when loads are added to arm

MUSCLE LENGTH IMPAIRMENTS

  • Based on length:  short pec maj/min and sh muscles
  • Based on alignment:  short serratus anterior, long trapezius and rhomboid

MUSCLE STRENGTH IMPAIRMENTS

  • Weak or long trapezius (upper, middle, lower) and rhomboid
  • Assoc w/muscle strain, resisted tests of scapular adductors weak and painful

ASSOCIATED SIGNS

ALIGNMENT AND APPEARANCE

  • May have normal resting alignment
  • Obesity
  • Large abdomen
  • Large breasts
  • Heavy arms
  • Thoracic kyphosis
  • Hypertrophied sh muscles

STRUCTURAL VARIATIONS

  • Long arms
  • Thoracic kyphosis
  • Scoliosis
  • Large or wide thorax
  • Common activities
  • Habitual abduction of shoulder girdle
  • Sit w/slouched posture
  • Activities involving reaching forward

MOVEMENT IMPAIRMENTS

SHOULDER FLEXION

  • Assoc w/impingement:  may have slight end-range limitation
  • Assoc w/tos:  may have numbness or tingling or other symptoms during arm elevation
  • Assoc/w instability:  may observe increased crease distal to acromiom; may also observe increased prominance of humeral head in axilla

PALPATION

  • May be tender over adductor muscle bellies if strained
  • Assoc w/impingement:  may be tender over coracoacrmio lig., bicipital groove,or rotator cuff tendons (supraspinatus)

SPECIAL TESTS

  • Assoc w/ tos:  may be tender over scalenes and pec minor; may reproduce symptoms
  • Assoc w/impingement:  tests reproduce pain; resisted tests of rotator cuff and biceps for soft tissue diff dx may be strong/weak and painful
  • Assoc w/instability:  may have increased accessory glide at gh joint in any direction

DIFF MVMT & ASSOC DX

DIFFERENTIAL SCAPULAR DIAGNOSIS

  • Scapular downward rotation
  • Scapular depression
  • Scapular winging and tilting

DIFFERENTIAL PRIMARY DIAGNOSIS

  • Humeral anterior glide
  • Humeral superior glide
  • Humeral medial rotation
  • Gh hypomobility
  • Cervical extension

ASSOCIATED DIAGNOSES

  • Rotator cuff tendinopathy
  • Shoulder impingement
  • Partial rotator cuff tear
  • Bicipital tendinopathy
  • Supraspinatus tendinopathy
  • Humeral subluxation
  • Tos and neural entrapments
  • Neck pain w/wout radiating pain
  • Pain or trigger points in rhomboids
  • Bursitis
  • Ac joint pain
  • Calcific tendinopathy
  • Subscapular bursitis
  • Snapping scapulae
  • Thoracic pain
  • Costochondritis
  • Teres syndrome
  • Sternal pain
  • Cervical or cervical thoracic pain

MED DX REQ. REFERRAL

MUSCULOSKELETAL ORIGIN

  • Cervical radiopathy
  • Brachial plexus injury
  • Rotator cuff tear
  • Fracture
  • Oa or ra
  • Glenoid labrum tear
  • Spinal accessory nerve palsy
  • Peripheral nerve entrapment

VICERAL ORIGIN

  • Neoplasms
  • Cardiovascular disease
  • Pulmonary disease
  • Breast disease
  • Abnormal organ pathologic condition

SYSTEMIC ORIGIN

  • Collagen vascular disease
  • Gout
  • Syphilis and gonorrhea
  • Sickle cell anemia
  • Hemophilia
  • Rheumatic disease

MOVEMENT TX

MAIN FOCUS

  • Main focus would be on stretching the short gh and th muscles and improving the performance of adductor component of lower and middle trapezius
  • Stretch pec maj/min…

QUADRUPED POSITION

  • Stretch humeral rotators int/ext rotation in supine position with hand weights

STANDING POSITION

  • Stretch/strengthen serratus anterior and stretch sh muscles
  • Patient faces wall and slides arms up the wall – at end of range adduct scapulae avoiding scapular depression
  • Progress to patients back to wall – increasing weight of arms – finally to prone position (same motion)

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