Shoulder pain w/ movement coordination impairments

Question 1

What conditions are included under movement coordination impairments?

Answer 1

• SICK scapula syndrome
• Posterior impingement (internal impingement)

Question 2

What does SICK Scapula syndrome mean?

Answer 2

seen in association w/ secondary impingement syndrome
- Due to overuse/fatigue of scapular musculature

S: Scapular malposition (lower position, lateral displacement)
I: Inferior medial boarder prominence (winging, ant tipping/tilting)
C: Coracoid pain and malposition (ant scapula tipping/tilting w/ pec minor tightness)
K: DysKinesis of scapular movement (uncoordinated muscle activity of force couples)

Question 3

What are the 3 types of scapular dyskinesis?

Answer 3

Type1: Inferior dysfunction
- prominent inferior angle due to ant tilt of scap
- most commonly found in pt w/ RTC dysfunction

Type 2: Medial dysfunction
- prominent medial scapular boarder due to internal rotation of the scapula
- most commonly found in pt’s w/ GHJ instability

Type 3: Superior dysfunction
- excessive, early elevation of the scapula during elevation (compensatory shoulder hiking)
- common w/ RTC dysfunction and deltoid RTC force couple imbalance

Question 4

Which positions show type 1 and 2 scapular dyskinesis?

Answer 4

• best seen in hands on hips position during active eccentric lowering from overhead position

Question 5

What is the MOI and clinical presentation of scapular dyskinesis?

Answer 5

MOI: insidious

History:
- OH athlete
- ant shoulder pain (most common)
- otherwise can occur almost anywhere in shoulder and/or cervical region

Exam:
- aberrant movements, postural deviations in neutral and hands on hips
- (+) scapular assistance test and wall push-up
- weakness posterior scapular musculature
- restricted muscle length of pec minor

Question 6

What is rehabilitation like for SICK scap?

Answer 6

• manual therapy and stretching for soft tissue restrictions
• periscapular neuromuscular retraining (scap PNF, closed chain push-up progression for SA)
• periscapular strengthening (prone I’s, T’s, Y’s, W’s)

Progression: mobility -> activation -> stability -> strengthening

Question 7

What is the pathway for posterior (interior) impingement?

Answer 7

anterior hyperlaxity -> full ER -> head of humerus slides anteriorly -> deep surface of RTC tendons impinge

Question 8

What is the MOI and history of someone with posterior (internal) impingement?

Answer 8

MOI:
- acquired anterior instability overuse
- hypertrophy of posterior capsule
- periscapular neuromuscular control decreased

History:
- OH athlete
- posterior shoulder pain
- “dead arm”

common to have associated SLAP tear

Question 9

What does an examination look like of someone with internal impingement?

Answer 9

• provocation 90-90 position
• muscular imbalance, lack of periscapular control
• ant instability/hyperlaxity
• decreased IR and increased ER (GIRD)
• rotator cuff signs and weakness
• SICK scapula
• popping, clicking, catching, sliding
• (+) special tests: posterior impingement sign, Jobe relocation test

Question 10

What are the 3 phases of internal impingement rehab?

Answer 10

Phase 1:
- control pain
- improve ROM
- restore muscle balance and endurance
- proprioception & manual therapy to c/t spine

Phase 2:
- dynamic stability in complex activities
- shoulder girdle strengthening

Phase 3:
- functional rehab to return to sport

Question 11

What are the overall goals of internal impingement rehab?

Answer 11

• be cautious of structural instability
• RTC strengthening and stabilization in closed chain
• improve GIRD (manual therapy, sleeper stretch
• Neuromuscular control of scapula: PNF, closed chain
• leg and trunk stability

Question 12

What are other conditions that can cause pain in the shoulder?

Answer 12

• cervical radiculopathy
• cervical facet dysfunction
• TOS
• lung, breast cancer