Shoulder and Scapular Diagnosis and Management

Educational Objectives

The goal of this program is to improve the diagnosis and management of shoulder pathology. After hearing and assimilating this program, the clinician will be better able to:

1. Identify the primary actions of muscles controlling motion of the scapula and shoulder.
2. Diagnose pathologic conditions of the shoulder and scapula.

Summary

Kinetic chain: alteration in properties of muscles affects entire body; local and distant biomechanics determine performance; evaluate kinetic chain by assessing leg, core, scapula, tightness of muscle, and rotator cuff; concept applicable to all patients (not limited to those with problems in shoulder); abnormality in contralateral hip found in ≈50% of patients with problem in shoulder

Anatomy: relevant components include humerus, glenoid cavity, scapula, acromion, clavicle, glenohumeral joint, acromioclavicular (AC) joint, sternoclavicular joint, and scapulothoracic articulation; glenohumeral joint lacks bony stability; stability derived from combination of capsule, labrum, surfaces of joints, and scapular rotators; muscles of rotator cuff include supraspinatus (abduction), infraspinatus (external rotation), subscapularis (internal rotation), and teres minor (depression of humeral head against glenoid cavity); lack of depression of humeral head indicated on x-ray may indicate problem with rotator cuff

Motion of shoulder: glenohumeral ligaments and labrum statically constrain humeral translation; rotator cuff provides dynamic constraint; importance of scapula underemphasized

Examination: evaluate patient without shirt; abnormal posture includes thoracic kyphosis, cervical lordosis, forward-head posture, or rounded posture; assess back for symmetry, bony prominence, deformity, and atrophy of muscle; assess from behind; include assessment of elbow and neck and of scapula at rest and during motion; palpate muscles

Scapular motion: includes up-down plane, internal-external rotation, and anterior-posterior tilt; most effective position retraction with external rotation, posterior tilt, and medial rotation on thoracic cage; allows acromion to elevate and facilitates lifting of arm; scapula must maintain ability to internally and externally rotate in synchronous pattern to maintain glenoid stability; assumes greater importance in patients without strong hips and core

Muscles of back: serratus anterior muscle most important for external rotation of scapula; lower trapezius muscle stabilizes scapula; upper and lower trapezius and serratus contribute to stability and mobility; rhomboid muscles assist with control; latissimus dorsi and pectoralis minor muscles affect movement of scapula

Force couplers: lower trapezius, rhomboids, and serratus anterior stabilize scapula; lower trapezius and serratus anterior work with upper trapezius and rhomboids to elevate acromion

Scapular dyskinesia: loss of control of scapular motion; observed in static or resting position; describes alterations in motion and function; etiology and patterns determine treatment; involved in 60% to 100% of all pathology of shoulder; alters glenohumeral angulation, AC joint, subacromial space, and optimal positioning of arm; related to bony factors, posture, or injury

Altered function of muscles: observed in 68% of patients with abnormalities of rotator cuff, 94% with labral tears, and 100% with glenohumeral instability causing scapular dysfunction; etiology — includes direct injury, injury to nerve, fatigue, and uncontrolled strain

Classification: type 1 inferior angle — inferior angle tilts dorsally during motion of arm because of abnormal rotation; often associated with tight anterior muscles and weakness of lower trapezius and serratus; prominence of medial border — abnormal internal rotation around vertical access or transverse plane; usually caused by fatigue in rhomboid and trapezius muscles; type 3 — superior border elevated and anteriorly displaced at rest

Postural syndromes: upper crossed syndrome — characterized by inhibited flexors of neck; tight pectoralis, upper trapezius, and levator muscles; and inhibited rhomboid and lower serratus anterior muscles; causes forward-neck and rounded posture; lower crossed syndrome — characterized by anterior pelvic tilt, tight rectus muscles, inhibited gluteal muscles, and tight thoracic lumbar extensor muscles

Tests: core — include bridge, plank, single-leg squat, and Trendelenburg tests; flexibility of hamstring, hip flexor, and rectus muscles — Thomas and quadriceps stretch tests

Sick scapula syndrome: characterized by scapular malposition, prominence of inferior medial border, pain in coracoid process, and dyskinesis (usually associated with tight pectoralis muscles and lowered shoulder); caused by overuse; patients present with pain in anterior shoulder, posterior shoulder, or lateral part of arm; physical therapy (PT) — goals to decrease tightness of posterior capsule and pectoralis minor muscle, increase activity of serratus and lower trapezius muscles, and minimize activity of upper trapezius muscle; prescribing “concern for scapular dyskinesis; work on scapular stabilization protocol” (as opposed to “shoulder pain”) facilitates evaluation and treatment by physical therapist

Rotator cuff impingement injury: diagnosis with highest prevalence; etiologies include injury, atrophy related to disuse, and apparent weakness caused by instability; consider scapular dyskinesis; excessive scapular internal rotation and anterior tilt cause loss of ability to raise acromion and scapular protraction; lead to ≈25% decrease in strength of rotator cuff; tests — include testing active and passive motion, Apley scratch test, testing strength of internal and external rotation, Jobe test, Neer test, and Hawkins test

Scapular assistance and retraction tests: corrective maneuvers that facilitate assessment of scapular dyskinesis; Kibler et al (2006) found strength of supraspinatus increased ≤25% through use of maneuvers; help re-enact action of force couplers; diminishment or elimination of symptoms of impingement indicates rehabilitation may be appropriate

Multidirectional instability: glenohumeral joint unstable; sulcus sign useful for assessing dislocation of humeral head; characterized by alteration of scapulohumeral rhythm, increased protraction, migration of humeral head away from center of joint, tight pectoralis muscles, activation of latissimus dorsi, and decreased strength of lower trapezius and serratus anterior; body compensates through activation of rotator cuff; treatment — focuses on increasing strength and stability of scapula and anterior flexibility of pectoralis muscles

Labral injury: associated with scapular dyskinesis; altered glenohumeral alignment places strain on anterior ligaments; internal impingement and strain on biceps and labral complex possible; treatment — focuses on scapular rehabilitation to improve retraction, mobilization of tight anterior muscles, and increasing stability

Parsonage-Turner syndrome: idiopathic neurologic problem involving brachial neuritis; usually associated with paresthesias and neuropathic pain in upper extremity; signs include scapular winging, weakness, and atrophy of muscle; many nerves can be affected; causes numerous; electromyography and magnetic resonance imaging appropriate; patients often present with diffuse pain in shoulder; treatment nonoperative; majority of patients recover with full strength and function in ≤3 yr without residual pain

Palsy of long thoracic nerve: causes weakness of serratus anterior muscle and elevation and migration of superior medial scapula; usually caused by repetitive stretching; other causes include compression and fracture of scapula; may be iatrogenic; signs include scapular pain and weakness on overhead activities; treated with PT; recovery requires ≈6 mo, cessation of causative activities, and restrictions on work (if appropriate)

Palsy of spinal accessory nerve: causes weakness of trapezius muscle and superior medial scapular depression on lateral rotation; treatment PT

Palsy of dorsal scapular nerve: can cause weakness of rhomboid muscles and pain along their vertebral borders

Readings

Hegedus EJ et al: Which physical examination tests provide clinicians with the most value when examining the shoulder? update of a systematic review with meta-analysis of individual tests. Br J Sports Med 2012 Nov;46(14):964-78; Kibler WB et al: Clinical implications of scapular dyskinesis in shoulder injury: the 2013 consensus statement from the ‘Scapular Summit’. Br J Sports Med 2013 Sep;47(14):877-85; Kibler WB et al: Evaluation of apparent and absolute supraspinatus strength in patients with shoulder injury using the scapular retraction test. Am J Sports Med 2006 Oct;34(10):1643-7; Martin RM et al: Scapular winging: anatomical review, diagnosis, and treatments. Curr Rev Musculoskelet Med 2008 Mar;1(1):1-11; Roche SJ et al: Scapular dyskinesis: the surgeon’s perspective. Shoulder Elbow 2015 Oct;7(4):289-97.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Northway was recorded at the Comprehensive Musculoskeletal Center Update: Shoulder Diagnosis and Management at Northville, held December 2, 2017, in Northville, MI, and presented by the University of Michigan Medical School. For information about upcoming CME opportunities from this sponsor, please visit ocpd.med.umich.edu/cme. The Audio Digest Foundation thanks the speakers and the University of Michigan Medical School, for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OR410601

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.