1. Sydney Physiotherapy Solutions
Matt Crawshaw Blair Chapman Chantal Wingfield

2. Today’s Topic is The Scapular
Shoulder pathology
Measuring static and dynamic scapular stabilisation
Using measurements to screen for prevention of shoulder injuries and to identify scapular dysfunction due to injury.
Using measurements to progress rehabilitation.
Shoulder is most mobile in the body = complex and prone to injury
Fundamental for our upper limb function as prox stability is paramount for distal control as we know with the core and trunk
My role today is to provide you with some food for thought regarding some of the potential pathologies your client’s may be experiencing and aiding you decision making regarding when you should refer on and who to.
In the following few slides we will go through each of these in more detail

3. Today’s Goal Interact and Share 2. Develop trust with you
discuss shoulder injuries from the Personal Trainers perspective
discuss shoulder injuries from the physiotherapist perspective
suggest a framework where the Personal Trainers and the Physiotherapists can be a team for the client with a focus on keeping them training with the Personal Trainer through their injury.
2. Develop trust with you

4. Framework for Physio’s and PT’s to work within When we receive a patient from a PT with a Shoulder problem
Our responsibility lies equally between the patient and the PT.
We need to establish a diagnosis and prognosis and communicate that to the patient and the PT.

5. Framework for Physio’s and PT’s to work within
To reduce Symptoms and address the likely poor scapular stabilising strategy that is present as a reaction to the injury.
To give patient back to PT with minimal Sx and a good scap stabilising strategy for the PT to load that strategy to regain full strength .

6. Framework for Physio’s and PT’s to work within
Important for the PT to understand how to identify good and bad scap stabilising strategies and to be able to monitor this during strength training.
We need to do this as soon as possible to maintain the relationship between patient and PT. If there is a longer period of rest required for the shoulder we need to provide the PT with safe strengthening exercises to do during the rehab process.

7. More detail of this Framework
Chantal is going to present the pathologies we are thinking of when a shoulder injury is referred to us from a PT and how we diagnose this.
Blair will describe the current understanding of scap stabilisation and how it is affected by injury. He will run a small practical session on how to measure and identify this for screening your clients before strength training and rehabilitating your clients back into strength training post injury.

8. Shoulder Pathologies Fracture Alternative considerations Dislocation
Cervical spine
Muscle tear
Thoracic ring dysfunction
Labral tear
Thoracic outlet syndrom / Brachial plexus
ACJ injuries
Peripheral neuropathies
Frozen shoulder
Tumors / lung Ca / heart
Arthritis
Subacromial impingement – including tendinitis, bursitis and postural dysfunctions
Shoulder is most mobile in the body = complex and prone to injury
Fundamental for our upper limb function as prox stability is paramount for distal control as we know with the core and trunk
My role today is to provide you with some food for thought regarding some of the potential pathologies your client’s may be experiencing and aiding you decision making regarding when you should refer on and who to.
In the following few slides we will go through each of these in more detail

9. Dislocation Usually traumatic Anterior most common
Be aware of the chronically unstable shoulder
Physiotherapy input recommended and usually imagery required as recurrence is highly likely
Surgical stabilisations occasionally required in presence of structural defect EG Bankart, unstable SLAP or Hill Sachs
Chronic instabilities
minor injury or repetitive micro-trauma or as a result of some action such as throwing a ball
Idiopathic connective tissue disorders – EG elhos danlos etc….

10. Muscle tear E.g. Rotator cuff but not exclusive
Can be traumatic or degenerative
Usually causes pain upper arm
Often but not always complain of weakness
Needs physio input +/- orthopaedic input depending on extent of tear/dysfunction & duration of symptoms
Diagnosed clinically with use of US or MRI as required
If traumatic, timing is key as better surgical outcomes within 3 months of injury
May require some rest from loaded upper limb work

11. Labral Tear
Can be traumatic or degenerative
Can be asymptomatic
Can cause clicking, feelings of instability or deep shoulder ache
Physio input recommended with ongoing PT.
Physio to guide re ex precautions & rehabilitate shoulder stability whilst training
So if you have a client with persistent clicking during overhead presses or ache post upper limb work outs etc – refer for an assessment.
Not definitively labral tear can be purely poor motor control / altered biomechanics (possible as a result of an alternative pathology) but if in doubt we can refer for an MRI with contrast 95% sensitivity whereas no contrast = 75%
Our aim will never be to stop their training with you but we may be able to suggest some ex options in early phases and will aim to get them back to you asap to continue full training and prevent further degeneration, reinforcement of poor motor control and ultimately limiting their long term training program
Occasionally surgical input required if unstable or fail conservative input
Caution with shoulder weight bearing and overhead loading during initial rehab phase

12. ACJ Usually managed conservatively
We will grade the injury and guide regarding their rehab and ongoing training
Avoid distraction / loading / weight bearing for ~ 2–6 weeks depending on grade of injury
Important to ensure normal mechanics post injury as can lead to secondary problems such as impingement
Can involve fractured clavical / collar bone or ACJ lig injuries resulting in step deformity and instability of ACJ as per picture
Lig strains usually managed conservatively
No loading / distraction / weightbearing for 6/52
Can help with some taping techniques

13. Frozen Shoulder AKA ‘Adhesive Capsulitis’
Inflammation and scarring of your joint capsule
Starts as a painful shoulder and develops into a stiff shoulder
More common in diabetics
Needs range maintenance exercises and occasionally onward referral for a corticosteriod injection or capsular release

14. Arthritis Osteoarthritis is also known as joint ‘wear and tear’
Older population
Stiffness and pain
Need careful grading of exercises, not too high loads as indicative that their cuff and labrum are severely degenerative
Very occasionally referred for shoulder replacement but outcomes currently limited. Good pain responses but ROM and strength outcomes poor so last resort.

15. Subacromial Impingement – Bursitis / tendinitis
Can occur post trauma, with overuse, sudden increase in training or gradual insidious onset as a result of poor biomechanics
Often occurs due to poor biomechanics this may be post RC, Lhbicep or labral tear, ACJ sprain or just as a result of poor posture and natural biomechanics eg depressed / protracted shoulder girdle
** discuss this in more detail
Head of hum pos
Posture***
RC function
Often present with am pain, pain post ex
Need physiotherapy input
If left untreated will worsen and reoccur. Risk of leading to degenerative tear.
May require US Ix, MRI to rule out underlying structural pathology eg labral or RC tear and corticosteroid injections can help
Surgical input controversial must exhaust conservative options before considering
Present with pain during arm elevation at end of range or often a painful arc and usually HBB also sore

16. Additional Potential Differentials
Cervical spine
Upper lung lobe
Cervical arteries
Heart
Thoracic outlet / brachial plexus
Peripheral neuropathy
Thoracic ring dysfunction
If unsure, refer to us and we will happily assess and give feedback
We utilise a series of clinical tests, questions and real time ultrasound to establish our diagnosis and then will develop a collaborative management plan with both you and the client
peripheral neuropathy can present with pain, weakness, loss of sensation or paraesthesia of the shoulder into the arm
Some of these include:
subjective
clinical tests
Real time US
Trial treatment options
Onward referral for MRI, US, Xray, etc…
Onward referral to an sports doc or othropod via GP if required

17. Scapular Mechanics

18. Scapular Movement

19. Muscle Actions Upward Rotation Serratus anterior, UFT,LFT
Downward Rotation
Levator scapula, Rhomboids,
Pec minor
Anterior/Posterior Tilting
Anterior: Pec minor
Posterior: LFT
Protraction/ Retraction
Protraction: Pec minor, serratus anterior
Retraction: Rhomboids, Trapezius as a whole (latissimus dorsi if humerus fixed)
External Rotation
Serratus anterior
Internal Rotation

20. Common Presentation As a result of injury or trauma
Downward rotation
Anterior tilt
Medial rotation
Which muscles are overactive?
Secondary Issues?
Talk about the cue back and down
Talk about the impingement that occurs due to poor position if doing overhead

21. Visual Assessment Kibler Classification of Scapular Dysfunction
Type 1 or inferior Dysfunction
Main feature is inferior angle prominence as a result of anterior tilting.
Best seen with hands on hips or eccentric lowering of arms from overhead ( most common in rotator cuff dysfunction)
Type 2 or medial Dysfunction
Prominence of entire medial border of scapula due to internal rotation of scapula.
Best seen with hands on hips, eccentric lowering from overhead
Common in shoulder joint instability
Type 3 or Superior Dysfunction
Excessive and early elevation of the scapula during elevation.
Ie. Shoulder Shrugging.
Often seen in rotator cuff dysfunction and deltoid rotator cuff force coupling imbalances
Studies support validity of visual observation of scapular dyskinesis

22. Rotator Cuff Function What is the function of the rotator Cuff?
Relationship with scapula
Arm abduction
(Lateral raises, military press)
Horizontal adduction
(chest press, fly’s)
Shoulder flexion
(front raises, boxing)

23. Observation Examples

29. Summary
Any questions ?