All right, hello everyone. Welcome to AAP virtual didactics today. My name is Amos Song and I am a third year resident at Vanderbilt and I will be your host. Your usual host Sterling Herring is off taking board exams so I will be filling in in the meantime. Before we get started I would like to take a moment to recognize those that have been both professionally and personally affected by this current pandemic with COVID-19. We realize that not all of us have been equally affected in this matter. The goals for these lecture series are to augment didactic curricula, to offload stretched faculty who may be facing new or changed clinical demands as well as to help provide learning opportunities for off-schedule residents as organizing logistical, as organizing resident didactics have presented some logistical challenges and also to develop more digital learning resources and to support presidiatrists during COVID-19. A couple of house rules. We'll be muting everyone's video and audio. This is just to preserve bandwidth and to give undivided attention to our speaker today. If you have any questions during the lecture you can click the participants link and you can look for my name Amos Song and I will ask those questions at an appropriate time. If you have any questions, suggestions, or concerns regarding these lecture series you can email Candice Street at that email address below and you can always find us on twitter at aaphysiatrists. Today we have Dr. Rex Ma coming from Rutgers in New Jersey. We're very happy to have him today. Welcome. All right. Can everybody hear me okay? Yep, we hear you great. Great. Do we need a video? I'm not sure if I have my video up as well. So I guess I think you're just going to have to if you scroll down to the bottom of the zoom screen you're going to see a upward facing green arrow. It's share screen. You're going to click PowerPoint and you should be good to go after that. Yes, let's see. PowerPoint. All right. So here we go. Share. All right. So let me just go from the beginning. All right. So so I'm going to start my presentation today and the title of my talk is actually Blades of Glory, the Story of the Scapula. So this lecture I have nothing to disclose I have nothing to disclose but just to begin when as an attending at Rutgers I get questions a lot about what how to evaluate the scapula and it is very confusing and so and I think it's very important for us to understand it firstly for those who are studying for the boards and and in terms of the board the most important question that we want to try to answer is how to evaluate the difference between the long thoracic, the spinal accessory versus the dorsal scapula nerves. Now that's going to be very important but for the most part that's not the most important thing clinically because we don't really see those often. In fact what is more clinically relevant and it was actually discussed in this summit on the scapula believe or not there's a scapula summit in which they talked about what the role of scapula dyskinesis in shoulder and neck pathology and what we found is that the there is a great association between the subacromial shoulder problems, AC joint problems, glenohumeral hypermobility problems as well as chronic neck pain. So in that sense you really get for your buck in terms of evaluating and looking at scapula conditions. So what we're going to do today is kind of give you a little roadmap of what's going on with the rest of the lecture. I'm going to really start with just trying to define what the scapula is and the nomenclature because I think that's going to be a very confusing part of what most people have in terms of their understanding. The next thing I'm going to do is to try to really define what scapula dyskinesis is and what it is not a physical examination. Then I'm going to be talking about what are some of the pathological causes of scapula dyskinesis. You will notice that I have two questions marks over here. I'm going to go a little bit more into that as the lecture goes along and then finally I'm going to talk about treatment considerations for the scapula or scapula dyskinesis. All right so are you ready? Here we go. All right the normal scapula. So what is the function of the scapula? Well this is kind of like when I first made this lecture and I spoke to and talking to the Kessler residents. I remember the first time doing this lecture was around 2008 and at the time there was a movie that came out that was named Blades of Glory and I thought wow that's not a bad name for this kind of lecture. Well the reason why I thought that this was a good name for this lecture is it's a catchy name but also if you actually for those who have seen the movie you will know that it's about two skaters working together as a team to create this what I would call an unforgettable performance and for those who have seen it you will know what I am talking about and for those who have not perhaps this is a good time with all the quarantining. Now basically what we would really want to know is is like what what does the scapula do? The most important thing it does is like it works as a team just like the skater here with the humerus like the skater over here and they work as a team and the scapula forms a stable base for the humerus to allow what would be like an infinite positioning possibilities of the arm. That is an amazing endeavor if you think about it. What it also does is that there is has a this is the base of where the glenohumeral muscle attachments basically the rotator cuff is where you have a lot of these and finally it forms a link between the proximal to distal kinetic chain. So now in terms of just things in general the probably what is very confusing about scapula and evaluation of scapula is the fact is the nomenclature and I think people get very confused over it and so I'm just going to go over that in a little bit more detail. The first thing that gets a little confusing is that the nomenclature for scapula is used for both position as well as for motion okay and position for the rotation is relative to the neutral anatomical plane. So what does that mean? So if we look at the upward rotation okay in this diagram over here this is the neutral position is the sagittal plane and anything to the right of this would be considered upward rotation and anything to the left of this will be considered to be downward rotation. Then when you look at the internal rotation and external rotation occurs along the superior inferior axis and the neutral plane is actually in the coronal anatomical plane and anything in front of it as it's moving would be considered externally rotated and anything below it would be considered internally rotated. And if you look at the tilting okay it is the actual rotation of the scapula along the medial and lateral axis and in the main it is also the coronal plane and anything going in front of it would be anteriorly tilted and anything going behind it would be posteriorly tilted. Now be very aware that there is this term with abduction and adduction. The problem with that is that it can mean multiple things and so for the most part I try not to use it in this lecture unless I'm clearly defined what it is. I have seen it used for protraction and retraction and I can also see it for upward rotation and downward rotation. So again I try not to use it because I find it to be a very confusing term. So in addition to rotation there's also movements that are what is called translation. And what is translation? Translation is just movement of the scapula that is not involving rotation. So you can have you go up and down so that's elevation and depression or you can go right and left which is on outside to inside which is kind of like if you go outside that's lateral translation and you go in it's medial translation. But as you all probably know the thorax is actually a three-dimensional object so if you go outward then what's going to happen is you're going to not only have a lateral translation but you're also going to have an internal rotation with it. And when you go inward which is what retraction is you're going to have a medial translation but you also will have a inner rotation. Again keep in mind that both are used these terms are used for both position and for motion. Okay and when you use it for position in this case you probably want to use it relative to the other side. All right so now that we have the nomenclature down let's look at what we would look at the next part and that's basically what the scapula would usually look like at rest. One of the things that we would always like to know is that there's going to be great variability. So it may not be what other people be like but for the most part you can see that the scapula is pretty internally rotated at its resting position. It is a little bit upwardly rotated and a little bit anteriorly tilted. So that's the usual position of what a resting scapula would be at. In addition you will see that for the most part the position of the scapula is around six centimeters lateral to the spine on average what most people would see on the average person. Another thing that we also want to kind of talk about is what exactly is the scapula humoral rhythm. And this is where it gets again very confusing for the average individual or the person who's trying to study this. And first let me define what it is. The scapula humoral rhythm is really nothing more than the combination and synchronization of the motion that occurs between the scapula and the humerus. Okay and Dr. Inman way back in 1944 actually described this ratio as being a uniform ratio of two to one. Of course if you actually read that article he actually had an n of one person. So probably not the most number of people that you can have in terms of a study. But what I would also caution everyone is that you're going to hear a lot of like oh the first 60 degrees as a three to one four to one five to one ratio and then the rest of them would be like a one-to-one ratio. Like I said I would caution you to actually say that just because what do we know about scapula humoral rhythm? Well scapula humoral rhythm varies with gender, it varies with the load that you're holding, it varies with hand dominance, it varies with the plane of movement, it varies with patients who are fatigued, patients who are overhead who are overhead athletes compared to the non-overhead athletes, and patients who are in pain. So for the most part you really can't rely on any particular ratio as the reason as the scapula humoral rhythm. All we can really say is that in the beginning the glenohumeral motion is a lot greater than the scapular thoracic motion. And as we get past around 90 degrees the glenohumeral rotation with the scapular thoracic rotation is going to be more to the one-to-one. And this is one of the studies that we I have cited for just to describe how widely these move zero even to 90 degrees. So here we go now that we talked about kind of positioning let's talk about elevation. Okay so this is I have a videos a bunch of videos here to see what the scapula does during elevation. So the first plane that we're going to use is going to be this plane over here the downward rotation versus upward rotation. Well I hope this works. So the the right the top is going to be flexion so we're just going to watch to see what the scapula actually does as it is doing its thing. And for the most part if you see this it is not hard to say that the scapula in this plane is doing upward rotation. So let's now look at the sagittal plane. So does the does the scapula anteriorly tilt or posteriorly tilt during flexion and during glenohumeral abduction? Let's see. So hopefully you can see what this actually does. So the humerus is going up and the scapula is going this way going this way. So hopefully you all get the sense that the scapula is posteriorly tilting. Now let's look at the last plane the axial plane and whether or not a the scapula is internally rotating versus whether or not it's externally rotating. So in flexion look at this it goes this way and in abduction it kind of goes this way. I'll let it finish. Okay and then so what do we think happened to this? Well I will tell you that if you were going to say hopefully you guessed or you evaluated correctly that during flexion the scapula internally rotates and during abduction or shoulder abduction the scapula externally rotating. Hopefully this video really kind of honed in what the scapula actually does during these kind of motion. Okay now the next thing we're going to talk about is now that we know the motions what are the muscles that involve with this motion? And then the muscles there aren't really that many that we have to be really keep in mind on but so the ones that we really need to know are the trapezius muscle which is right here from the upper middle to lower there is the serratus anterior which is this muscle right over here there's the rhomboids major and minor okay and there's the levator scapula and there is the pec minor don't forget the pec minor inserts onto the carotid which is part of the scapula. Now we can do it this way but we I think what it might be more helpful is to kind of group these muscles into what it does in a certain position or rotation. In terms of the scapula elevation the muscles that are involved with that would be the upper traps levator and rhomboids in terms of scapula depressors there are the the pec minor serratus as well as the lower traps. In terms of the retractors there are the rhomboids middle traps they also claim the latissimus dorsi but it doesn't really probably do too much. In terms of protractors hopefully you'll be able to understand this is the serratus anterior and the pec minor the way they do this is actually pull this and pull the tracks to protract the scapula so that's how it usually works. Now for a very important aspect of elevation is the upper rotators and for the most part the three main upper rotators are the upper traps the lower traps and the serratus anterior. For the downward rotators which is what goes against the upper rotators the ones that are most important are the levator the rhomboids and the pec minor okay. Now into these rotations there's also the other two rotations that we're talking about The internal rotation, external rotation, and the tilting. Now in terms of the tilting and internal rotation, there's only one that does anterior tilt and internal rotate, and that's the pec minor. Again, if you, as I'm going with this lecture a little bit later, you'll understand that these two motions are what causes a lot of what people term scapular dyskinesis. So it makes sense that this muscle becomes very important for a muscle to look at when it comes to dyskinesis. The other muscles that are also important are the ones that are responsible for posterior tilting, which are the middle and lower traps, the middle and lower serratus anterior, and the lower trapezius. And the ones that are involved with external rotation is the serratus anterior and the middle and lower trapezius. So now that we're done with the normal scapula, let's kind of define what the scapular dyskinesis actually is. Well, the first thing I would say is what scapular dyskinesis is not. Scapular dyskinesis is, if you think about where the origin of that term comes from, it's really more about motion. So if you see a patient at rest, and they're not moving, you probably shouldn't be using the term scapular dyskinetic or whatever, that something similar to that. The official recommendation from the scapular summit is to use the term altered scapular dyskinesis. And that's a little bit wordy. Whatever you choose, the best thing is basically, I'm just going to describe what you should be looking for when you're looking at a patient at rest. So what you're looking for is asymmetry and describe the position. You want to see whether or not a scapula is elevated, depressed, protracted, retracted, upwardly rotated, downwardly rotated. So I think just in this case, if you look at the right scapula, this right scapula seems to be somewhat more downwardly rotated than the other scapula, which kind of looks on the left scapula, which looks like it is upwardly rotated. So that's something that I would describe. Okay. Another thing you can also do is to measure the distance between the midline to where's probably the best place to measure is the inferior medial border of the scapula. Okay. If you measure that, you probably would get a whole lot of good information already. Then, so what is scapular dyskinesis? Before I go further, I just wanted to kind of describe another term that people also use is called scapular dyskinesia versus scapular dyskinesis. Now, I think this is mostly semantics and you can probably interchange between the two, but for those people who are very particular about terms, scapular dyskinesia is probably more the notes of a neurological condition as opposed to a scapular dyskinesis, which is more of a general condition. And what is scapular dyskinesis? Well, the thing that most people think about when they think about scapular dyskinesis is winging. Okay. And what is winging? Winging is really nothing more than an abnormal prominence of the medial border or inferior scapular border during arm motion. Okay. And the term abnormal is all relative. Okay. And that's really all winging is. Now, if you were going to kind of define further about what winging is in terms of the rotation position, winging is more likely when a scapula is less upwardly rotated. It happens more when there's more anterior tilt and it happens when there's no rotation. Another type of scapular dyskinesis is called dysrhythmia. And basically what dysrhythmia is, is an abnormal scapular humeral rhythm, and it can be due to one of two things. Now, this video is a very interesting video. Watch both of these. Now, these two patients both have glenohumeral range, like the range of the, is around less than 90 degrees. Check out the one on the left and the one on the right. Okay. Now, even though they have the similar range of motion, the reason why they have this is completely different. If you look carefully on the patient on the left, the patient has a problem elevating the scapula. So he has good glenohumeral motion, but poor scapular thoracic control. The patient on the right is exactly the opposite. The patient on the right has really good scapular thoracic motion, but very limited glenohumeral motion. And as a result of that, the patient, you will see, you know, limited range of motion. Again, I thought this was a very good example as to two conditions causing a similar exam, but for two completely different reasons. All right. So now, now that we know the definition of scapular dyskinesias, how do you evaluate it? Well, this was something that was very interesting that was talked about in the summit. And what they really have probably true is that a detailed evaluation for scapular dyskinesias is probably too difficult for the average clinician. And it's not that it's, you know, not any knock on the clinician, but when you make something very difficult, it's going to, it's going to hurt the inter-rater reliability of any physical exam. And you don't really want to do that. And so what the recommendation is, is what is called the dynamic scapular dyskinesias. And this is decided by us with mild variation between the two, but what they found is that it's got very good inter-rater reliability, which is actually going to be very good. And really what you're looking for is a yes, no question. Does the patient has dyskinesias? Does he not have dyskinesias? And that's pretty much it. So the scapular dyskinesias is like this. You have a patient do three to five reps of active range of motion inflection and an abduction. Okay. And then scapular dyskinesias. And when I mean scapular dyskinesias, I mean winging or dysrhythmia. Okay. If there is no scapular dyskinesias, no further testing is necessary. That's it. No, it's that, that's all it needs to do. So, and you'll be done. Now, unfortunately, a lot of times it doesn't happen that way. Well, before I go further, why is it that they actually want you to test you with abduction as well as flexion? Well, the main reason is because of these, of the, of the difference in muscle activity of the rare entities during abduction and during flexion. In abduction, the serratus anterior, as you see here, is very, very low. Okay. Almost non-existent when you do an abduction. While the activity of the trapezius is actually quite high. And the more you go, the higher it gets. Now, this contrast with flexion, inflection, you see the serratus anterior muscle going higher. Okay. As you are elevating, as opposed to, again, what you saw, abduction, which actually didn't have much activity. But one thing you also want to know is that inflection, it doesn't, the trapezius activity doesn't shut down like the way that abduction does with the serratus anterior. The, the trapezius actually also goes, goes down as, and the trapezius activity actually maintains its high activity during flexion. All right. Now, if you did have a positive scapular dyskinesis test, and if you have pain with it, then the recommendation is to add what is called the scapular assistance or scapular retraction test. And what are those two tests? Well, these are tests that actually manually, that help manually support the scapula while a palpification test or motion are repeated. So basically what that means, if somebody comes in with painful range of motion, what you do is you will do one of these. For the scapular assistance test, what you're going to do is you're going to push on the scapula while the patient is doing that motion. And for the scapular retraction test, what you're trying to do, and it gets a little bit complicated to try to do this, is to grab the AC joint, put your forearm on the scapula on the medial border and push on it while you're repeating the palpification test. Either of the two, if either of the two is considered positive when the manual support improves the symptoms. Okay. And it indicates that the scapular dyskinesis is probably a contributor to the pain. And then if there is a contributor to the pain, then perhaps doing exercise to improve the scapular dyskinesis may be useful. So then for most people, you can probably just end your physical exam right there. But there are probably some people who wants to go one step further to evaluate the scapula a little bit more. And why would we want to do that? There are studies that show that if you can localize the problem through a thorough physical exam, it could be helpful in narrowing down the appropriate exercises. And because of that, that might be something to consider. So I'm going to go through a little bit of a deeper area on that. Okay. What are the two things that you want to evaluate for? Would you evaluate for tightness or you evaluate for weakness? So which muscles are weak and which muscles are tight? Well, there's actually an algorithm from Dr. Cruz, I think from Belgium. And she actually went through a whole lot of different treatment for the algorithm for the scapula. And basically what we are looking at, the main things that we are most focused on are these structures. And from us, I'm going to be talking about the pec minor, the posterior capsule, and how to assess for strength testing for the lower middle traps and the serratus anterior. Okay. So focus on them. When the pec minor is tight, it will pull on the coracoid. Okay. And what happens when that happens? Well, it will result in greater internal rotation, more anterior tilting, and more downward rotation. And then actually, basically, if the symptoms are severe enough, will cause this, scapular dyskinesis. You see that. Now, in terms of testing for the pec minor, there is no consensus as to what the best test is. So with that in mind, I was thinking, given you were going to do a test, probably do one that's the most simple. And that is what is called the pec minor length test. Basically, what you do, it's an indirect assessment of the pec minor length. But what you do is have the patient lay supine and just measure the distance between the table to the spine of the scapula. If that distance is greater than one inch off the table, then there is presumed shortening of the pec minor. The other thing that you also want to talk about is tightness of the posterior capsule. When you have tightness of the posterior capsule, what's going to end up happening is you're going to start having a deficit in the glenohumeral internal rotation. And there's a term for that called GERD. And when you have a deficit in the internal rotation, what's going to end up happening for the purpose of the scapula is that it's going to increase the anterior tilt when you are trying to internally rotate, causing more scapular dyskinesis. So how do you assess for that? Well, for the most part, you want to assess with the scapula stabilized, and you just want to assess for how much internal rotation there is for the patient. Normally, it is around 90 degrees. For those of you who may be doing more of a sports program, what the literature is suggesting that not only should you be doing the internal rotation, you should also be assessing the external rotation. Again, I'm not going to go into too much detail with that because it gets a little bit too confusing. To diagnose GERD, to just keep it simple, is if you have a patient who has more than 20 to 25 degrees of deficits in internal rotation. So now let's talk about strength, okay? One of the muscles that tend to be weak is the serratus anterior. And how do we best assess it? Well, this is one way that I think is pretty good. If you have a patient either inflection or scaption to around 125 degrees, and you resist, this actual activity has the highest serratus anterior activity on surface EMG. And the way you monitor for is that you just make sure that this line doesn't get broken, okay? And what weakness that you're going to see is between the thorax and the scapula, okay? And that's what you got to see. So this patient has clear serratus anterior weakness, and you can see that the interaction between the scapula to the humerus is relatively intact. Now, the next test that you would want to try to do is the middle trapezius strength test. How do we do that? Well, you basically want to have the patient prone and abduct and putting resistance down whilst the thorax, okay? And you again look for any deviations between the thorax to the scapula. This could be a very difficult maneuver for people with shoulder pathology. Next, the lower trapezius is another test that you may want to try. And the way to do that is to actually have the patient elevate from this position, because this position is parallel to the fibers of the lower traps. And when you do that and you resist, you also again look for any deviations between the scapula from the thorax. Again, this position can be also very difficult for patients with shoulder pathology. All right, so we are done with the physical exam. Now, as I said before, let's go over some of the pathological causes of scapular dyskinesis. The reason why I put these two question marks together is because, you know, when I say this, I'm almost saying that the pathology causes dyskinesis. Do we really know for a fact that is the case? I think the better way of asking is what can can pathology cause dyskinesis or does scapular dyskinesis cause pathology? And that's one of those questions that we have to try to answer. Really, this is what the literature actually shows. And it really is the classic kicking and the egg scenario. Okay, and I'm just going to present the data to you. Scapular dyskinesis is often seen with both neck and shoulder pathology, multiple studies. So that's pretty much a given. When we try to experimentally induce the pain by putting hypotonic saline into the subacroma area, it did result in changes in the scapulothoracic muscle. But for the most part, the results are always different depending on who you read. So really inconsistent results. In addition, what we also found is that people who are overhead athletes, scapular dyskinesis are often seen. And these people have no symptoms whatsoever. And you'll be like, okay, so this might be a one. But then if you look at this study, there is a meta-analysis that showed that asymptomatic athletes with scapular dyskinesis would have a 43% greater risk of developing shoulder pain than those without. So there is a cause, possibly. So what's the conclusion to this? Well, at this point, all one can say is that there is an association between the two. So really, we don't really know which cause and which is the effect at this point. Now, let's look a little bit on the nerve injuries, because that's what we're kind of talking about when it comes to the boards. Now, for the most part, when you look for somebody and you see scapular dyskinesis, you should probably not be thinking to yourself that this is a nerve injury because it's relatively uncommon. In fact, less than 5% of the patients will have scapular dyskinesis. But like I said, it's important for the board, so we got to have to go through each one. Pain really doesn't help in terms of defining each one, all of them. The history, on the other hand, may be important. People with spinal accessory nerves are usually traumatic in nature, and they're related to head and neck surgery. For the long thoracic lesions, they can also be traumatic, non-traumatic, or idiopathic. But the one thing you want to make sure you know is whether or not a patient associates you with parsnish, Turner, and or brachial... So scapula is a very uncommon, the least common of them all, and it's likely an entrapment, but the exact location is not known. So the best way to diagnose is through a physical exam. So let's look at this. We're going to be doing like a scapula dyskinesis test now, okay? So basically what we're seeing is a patient who has a serratus anterior weakness. And you can look, it's going to be on the right-hand side. And you look, compare at rest to see where is that compared to the other side. Well, when you talk about serratus anterior weakness, it's usually what most people think about is medial winging. And the term medial winging really only means where the scapula is winging, not how it's winging. So for serratus anterior weakness, the winging happens more upwardly and closer to the spine, okay? And the way I usually try to remember this is what does the serratus anterior do? Well, it depresses, it protracts, and it upwardly rotates. So when you don't have the serratus, it does exactly the opposite. It's more medial and it's rotated downward, as in this case. And then what happens with active range of motion? Well, this is what happens with active range of motion. You're going to see the person kind of flex and significant, significant scapular dyskinesis with flexion, okay? And then you're going to see, if you come down, and then you're going to see abduction. And you're going to see what happens with abduction. And for the most part, abduction is affected, but not as much scapular dyskinesis. And the reason for that is what I went through before. The serratus anterior is much more needed for flexion than during abduction, okay? So that's serratus anterior weakness. For the trapezius, it's exactly the opposite. It's the lateral winging. And again, go back to what the trapezius does. It elevates upper traps, it upwardly rotates the upper trap and the lower trap, and it retracts the middle trap. So what would it look like at rest? Well, it will probably look more lateral. It may look more depressed, and it's downwardly rotated. So in this left arm, it's the left scapula that's the problem, okay? And you're going to see what happens with motion. So it's going to be downwardly rotated during abduction, and you're going to see him go flex. And you see some of it, but he flexes very well with the scapula. But very difficult with abduction. And you can also see, if you really look at him, he's cheating a little bit. He's actually doing more of a scaption than he is doing full abduction. And that's just how people compensate when they have a weakness. As opposed to the rhomboid weakness, that's actually something that we don't see very often, okay? In this case, this is a case report of a picture of somebody with rhomboid weakness. And basically what happens is, what does the rhomboid do? The rhomboid elevates, downwardly rotates, and retracts. And what does it look like at rest? It will be lateral, it will be depressed, and it will be rotated upward. And then when you do active range of motion, it might actually decrease the amount of scapula winging. And for the most part, the findings are more subtle than any of the other two. And then the treatment is therapy for at least 12 months. But generally, the people with serratus anterior and rhomboid do much better than people with trapezius palsy. And for those who don't do well, you can try a brace. And if the conservative treatment fails, you can do fusion, muscle transfer, and nerve repair. Alright, we are done with that. And then finally, let's talk about the treatment considerations. Now, this is just a review of what we have mentioned so far. Evaluating the patient with scapula dyskinesis. First, you do a dynamic scapula dyskinesis test. Does the patient have or have not? If they have, okay, great. If they don't, nothing else that needs to be done. If they have and they're not symptomatic, also there's not that much to be done. Then what you can do is to do either a scapula retraction or scapula assistance test. Is it more, is it positive? If it is, then scapula exercises may be more helpful for a positive test. You want to evaluate for the most part, this is really beyond the scope of this lecture, so I'm not going to go much further than that. And then finally, what you would do is to evaluate and treat the imbalance. This is something that we will go over for our exam, for the rest of the lecture. And let's use the rotator cuff tendinopathy as an example. This is a really nice diagram of all the things that can be reasons for rotator cuff tendinopathy. And in it, you can see that scapula kinematics is a factor, but not the only factor in the cause of rotator cuff tendinopathy. So that also means that in terms of treatment, that could be a part of the treatment, but not the total treatment. So you get my direction to which I'm going to with this. What does the scapula dyskinesis do in subacromial impingement syndrome? Well, the bottom line is this. It decreases the acromial humeral distance. And this is the acromial humeral distance that we're talking about here. And when you decrease the acromial humeral distance, and remember the acromion is part of the scapula, when you decrease the acromial humeral distance, you're going to increase the risk of extrinsic impingement. And here's a video of what the scapula dyskinesis looks like. Now, just look, before I start, let's take a look at the border. This is the right side. You can see that this side is a little bit more elevated. It's more prominent, with a little bit more internally rotated. Now, let's take a look at the video on... Now, look at this. As she's coming down, you're going to see that there's going to be a little bit prominent. Traumatic, but just there. And so this is what you would expect to see for a typical person with scapula dyskinesis. So what is the evidence for inclusion of scapula exercises for rotator cuff tendinopathy and subacromial impingement syndrome? Well, there's multiple studies that says that scapula exercises is helpful for both improving symptoms and scapula dyskinesis. A very recent systematic review actually found that there is some beneficial benefits in reducing pain and disability, but they didn't feel that convinced that there is enough of evidence that the effects of exercise can improve the scapula position and motion. So how long is this? What is my thought on this? Is that I feel like there are enough positive publications to justify incorporating the scapula exercises as part, again not total, as part of the comprehensive rehabilitation program for rotator cuff tendinopathy. And so now, what do we do in terms of things that we can do to help with that? Well, let's look at the left-hand column first. Okay, and this is the flexibility column. So how do we stretch the pec minor? Well, it's a good question and it's a lecture on itself about whether or not stretching actually helps or does not help. But basically, they found in terms of the pec stretching, if you were going to do a pec stretch, the lateral corner stretch is probably your most effective stretch, okay? But there is problems with this stretch in that some studies have shown that it is good and it changes the scapula kinematics. Other studies did not show that, but pain and puncture improved for patients with shoulder pain. And a lot of times, this is not universally accepted because it puts a patient in somewhat of an impingement position. Kinesio taping is another option that I have seen more and more on this about changing it. And what do we know? It does seem to change the scapula kinematics, okay? But what we probably can conclude is that kinesio taping is good, but it's not sufficient enough to just use it as the sole treatment. If you use it in complementary to an exercise program, there's probably some good data on it. And the one thing that you kind of have to keep in mind with any of these kind of modalities is what's the long-term benefit? Once the tissue can do it, is it going to return? In terms of GERD, remember we talked about GERD, what is the best stretch? Probably the best stretch I would recommend is the cross-body stretch. And basically, McClure actually compared the sleep stretch, which is not a bad stretch too, and the cross-body stretch, and it seems like the cross-body stretch was a little bit better than the sleeper stretch, although not significantly better. Now the sleeper stretch can also kind of cause some pain for some patients. So that could be also a limitation as well. So this is why I think I would recommend that. And keep in mind, when you do the stretch, you want to make sure that the scapula is stabilized if you were trying to stretch the capsule. If you were doing the rhomboids, then you would leave it without stabilizing the scapula. So now let's look at the strengthening aspect of it. So the strength, what are the things that we kind of have to do for the strength? Well, we want to first do the muscle control, and then we want to do the strength. And how do we do muscle control exercises? Dr. Kibler, who is really the father of a lot of the scapula dyskinesis talk, developed four exercises that are very good for co-contraction, because he thinks, and we do know that, scapula dyskinesis often occurs because of poor neuromuscular control. So you will start with these two exercises, the isometric, I mean the inferior glide or the low roll, both of which are exercises. Then you will progress to the lawnmower and the robbery. And these are more functional exercises. And then, this is just a study recently about these four exercises and how it affects the levator scapula and the pec minor. But I don't think I'm going to go talk too much about that. Now, another way, another thing that we have to consider when we are talking about strengthening is improving muscle imbalance. For a lot of these patients with scapula dyskinesis, it's not just about weak, because we also found that some muscles are very hyperactive. And what that means is that, if we're going to use the example of the upper rotators, what they have found in this study is that the upper traps becomes very overactive and the lower and the middle trap is very weak. And in this example, it is like a really athletic person and two toddlers trying to rotate this carousel together. And when they try to do that, you can just imagine the bad result that can occur as a result of that. So what is the strategy? The strategy is trying to change that into more like this. Kids who are all around the same age who can push this carousel and be synchronously pushing it together. So that's the strategy that we're going to try to do with this. And then for you to do that, you're going to have to know which are the muscles that are usually tight and which are the muscles that are usually weak. And these are the muscles that are tight and these are the muscles that are usually weak. And the only overlap between the two is probably the upper traps. So what are some of the exercises? We talked about the upper traps. How do you manage upper traps while improving serratus anterior and lower traps? Well, these are exercises that have been proposed. These are good for the serratus anterior and these are good for the lower and the middle traps. And then you can go through the literature, the article if you want to have more details about that. In terms of other types of hyperactivity, protraction is also a very important part as well. If you can imagine both the pec minor and the serratus anterior are both protracted, you certainly don't want to be activating the pec minor to make it more tight. But at the same time, you want to activate the serratus anterior. So what do you do? Well, this is a good exercise to do. It's called the serratus punch. And this is actually a good one for that. And for those of the muscles that do have weak upper traps, you may want to do these exercises called the oval head shrug to minimize the activity of the levator and rhomboids while trying to improve the sharp traps. So I'm just going to kind of end with an example of this program. PT program that involves scapular exercises. These are six exercises that they said for a patient. And they actually did a study on this. They used these six exercises for patients who have rotator cuff tendinopathy and compared to a regular program. If you look, five of these exercises have a scapular component in it. And what did they find? They actually followed these patients for five years. And at that time, at the end of this study, they found that there was significant pain, improvement pain in both groups. However, they found that the scapular exercise group has significantly less surgeries. So that's a good thing. So let's just kind of go through everything that we kind of went through today. So in conclusion, just wanted to point out a few things. We want to understand that evaluating and understanding scapular dyskinesis does not have to be complicated. It can be done with two simple tests. The dynamic scapular dyskinesis test and one or the other of the scapular retraction or scapular assistance test. You'll want to understand that the scapular plays a role in various cervical and shoulder conditions. Although, even as the Scapular Summit folks have said, the exact role is really not clearly defined. We also want to know that incorporating scapular exercises as part of a comprehensive program for treatment of these conditions may optimize the outcome. So that's my conclusion. And what we're going to do, and this is actually a link to all my references. So if you guys are curious, go ahead and look at that. Any questions? Dr. Ma, thank you very much. This is a really great lecture. Scapular dyskinesis is definitely one of those more nebulous terms here. So we do have a couple of questions from the audience. The first one here from Zane. He says that you mentioned physical exam testing for both trapezius and serratus anterior. Is there a validated exam maneuver for testing rhomboid strength? Not that I know of at this point. If there was, I have to look through it. But I don't know of something offhand at this point. Gotcha. Another question here. Usually they say that scapular dyskinesis can be secondary to other shoulder pathologies, as you mentioned, in particular with labral injuries. When you treat these, do you go after the labral injury first, or do you go after the scapular dyskinesis first? I would say that it depends on what you mean by going after the labral injury. Traditionally, for most labral injuries, it should be treated conservatively first unless you are a high-end athlete, and I think a high-end overhead athlete in that case. And so if you were going to treat it conservatively, then you definitely want to incorporate scapular exercises as part of your program, especially if you see, again, you do the scapular dyskinesis test. It's a type of scapular retraction test. So that's how I would go about doing that. I see. I think we have time for one last question here. Is there any variation in normal scapular movement? Is there a wide range, or is it pretty much consistent throughout most patients? It is very wide range, and it is one of those that this is why the folks, and I agree with the folks in the Scapular Summit, to not really go into too much detail about the wide range, about just doing the details of the exam. All you really want to do is just to see if there's any prominence or not prominence, and I think that the reason for that is because of all the wide range. Gotcha. All right. Well, Dr. Ma, thank you very much for your time today. I definitely learned a lot from this lecture. If you want to look for the full schedule, Zoom details, and past lectures, all these lectures are recorded. You can find this on that URL on your PowerPoint slide. If you have any questions, you can find Dr. Ma at the Twitter handle there. I do not have social media, but you can find Sterling Herring as well as AA Physiatrist on Twitter. Thank you very much for your attention today. Please hang on for the second lecture if you have some time. Thank you.

scapular dyskinesis

shoulder conditions

abnormal scapular motion

dynamic scapular dyskinesis tests

scapular exercises

rotator cuff tendinopathy

subacromial impingement syndrome

strengthening exercises

individualized treatment