The Rotator Cuff - ChiroUp

Scapular Dyskinesis Summary (Continued)References1. Van der Windt DA, Koes BW, de Jong BA, Bouter LM. Shoulder disorders in general practice: incidence, patient characteristics,and management. Ann Rheum Dis, 1995;54(12):959-964.2. Kibler WB, McMullen J. Scapular dyskinesis and its relation to shoulder pain. J Am Acad Orthop Surg,2003;11:142-151.3. Warner J.J.P, Micheli L.J, Arslanian L.E, Kennedy J, Kennedy R. Scapulothoracic motion in normal shoulders and shoulders withglenohumeral instability and impingement syndrome. Clin Orthop Rel Res. 1992;285:191–199.4. Oyama S, Myers JB, Wassinger CA, Daniel Ricci R, Lephart SM. Asymmetric resting scapular posture in healthy overhead athletes. J Athl Train. Oct-Dec 2008;43(6):565-5705. Kibler WB, McMullen J. Scapular dyskinesis and its relation to shoulder pain. J Amer Acad of Orthop Surgeons 2003;11(2):142151.6. Cools AM, Dewitte V, Lanszweert F, et al. Rehabilitation of scapular muscle balance. Am J Sports Med 2007;35:1744–51.7. Borstad JD, Ludewig PM. The effect of long versus short pectoralis minor resting length on scapular kinematics in healthyindividuals. J Orthop Sports Phys Ther 2005;35:227–38.8. Sahrmann S. Diagnosis and treatment of movement impairment syndromes. St Louis: Mosby, 2001.9. Kibler WB, Ludewig PM, McClure PW, et al. Scapula summit 2009. J Orthop Sports Phys Ther 2009;39:A1–13.10. McQuade KJ, Dawson JD, Smidt GL. Scapulothoracic muscle fatique associated with alterations in scapulohumeral rhythmkinematics during maximum resistive shoulder elevation. Journal of Orthopaedic and Sports Physical Therapy. 1998;28(2):74-80.11. Kebaetse M, McClure P, Pratt NA. Thoracic position effect on shoulder range of motion, strength, and three-dimensionalscapular kinematics. Arch Phys Med Rehabil 1999;80:945–50.12. Finley MA, Lee RY. Effect of sitting posture on 3-dimensional scapular kinematics measured by skin-mounted electromagnetic tracking sensors. Arch Phys Med Rehabil 2003;84:563–8.13. Gumina S, Di Giorgio G, Postacchini F, Postacchini R. Subacromial space in adult patients with thoracic hyperkyphosis and inhealthy volunteers. Chir Organi Mov. Feb 2008;91(2):93-96.14. Kibler WB, Sciascia AD. Current concepts: scapular dyskinesis. Br J Sports Med 2010;44:300–5.15. Kuhn J, Plancher K, Hawkins R. Scapular winging. J Am Acad Orthop Surg 1995;3:319–25.16. Shailen Woods Comprehensive Approach to the Management of Scapular Dyskinesia in the Overhead Throwing Athlete.UPMCPhysicianResources.com/Rehab17. Seitz AL, McClure P, Lynch SS, et al. Effects of scapular dyskinesis and scapular assistance test on subacromi space duringstatic arm elevation. J Shoulder Elbow Surg 2012;21:631–40.18. Atalar H, Yilmaz C, Polat O, et al. Restricted scapular mobility during arm abduction: implications for impingement syndrome.Acta Orthopaedica Belgica 2009;75:19–24.19. Silva RT, Hartmann LG, Laurino CF, et al. Clinical and ultrasonographic correlation between scapular dyskinesia and subacromial space measurement among junior elite tennis players. Br J Sports Med 2010;44:407–10.20. Smith J, Kotajarvi BR, Padgett DJ, et al. Effect of scapular protraction and retraction on isometric shoulder elevation strength.Arch Phys Med Rehabil 2002;83:367–70.21. Kibler WB, Sciascia AD, Dome DC. Evaluation of apparent and absolute supraspinatus strength in patients with shoulderinjury using the scapular retraction test. Am J Sports Med 2006;34:1643–7.22. Mihata T, McGarry MH, Kinoshita M, et al. Excessive glenohumeral horizontal abduction as occurs during the late cockingphase of the throwing motion can be criticial for internal impingement. Am J Sports Med 2010;38:369–82.23. Lukasiewicz A.C, McClure P, Michener L, Pratt N, Sennett B. Comparison of 3-dimensional scapular position and orientationbetween subjects with and without shoulder impingement. J Orthop Sports Phys Ther. 1999;29(10):574–586.24. Ludewig P.M, Cook T.M. Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement. Phys Ther. 2000;80(3):276–291.25. Schmitt L, Snyder-Mackler L. Role of scapular stabilizers in etiology and treatment of impingement syndrome. J OrthopSports Phys Ther. 1999;29(1):31–3826. Uhl TL, Kibler WB, Gecewich B, Tripp BL. Evaluation of clinical assessment methods for scapular dyskinesis. Arthroscopy. Nov2009;25(11):1240-124827. Postacchini R, Carbone S. Scapular dyskinesis: Diagnosis and Treatment. OA Musculoskeletal Medicine 2013 October18;1(2)2028. Kibler WB. The role of the scapula in athletic function. Am J Sports Med 1998;26:325–37.29. Odom C.J, Taylor A.B, Hurd C.E, Denegar C.R. Measurement of scapular asymetry and assessment of shoulder dysfunction us-

Scapular Dyskinesis Summary (Continued)ing the Lateral Scapular Slide Test: a reliability and validity study. Phys Ther. 2001;81(2):799–809.30. Gibson M.H, Goebel G.V, Jordan T.M, Kegerreis S, Worrell T.W. A reliability study of measurement techniques to determinestatic scapular position. J Orthop Sports Phys Ther. 1995;21(2):100–106.32. McClure PW, Tate AR, Kareha S, et al. A clinical method for identifying scapular dyskinesis: part 1: reliability. J Athl Train2009;44:160–4.33. Tate AR, McClure PW, Kareha S, Irwin D, Barbe MF. A clinical method for identifying scapular dyskinesis, part 2: validity. J AthlTrain. 2009;44:165-173.34. Kibler B, et al Clinical implications of scapular dyskinesis in shoulder injury: the 2013 consensus statement from the ‘scapularsummit’ Br J Sports Med April 201335. Awan R, Smith J, Boon AJ. Measuring shoulder internal rotation range of motion: a comparison of 3 techniques. Arch PhysMed Rehabil. 2002;83:1229-1234.37. Tate AR, McClure PW, Kareha S, Irwin D. Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in overhead athletes J Orthop Sports Phys Ther. 2008 Jan;38(1):4-11.38. Struyf F, Nijs J, Mollekens S, Jeurissen I, Truijen S, Mottram S, & Meeusen R (2013). Scapular focused treatment in patients withshoulder impingement syndrome: a randomized clinical trial. Clinical Rheumatology, 32, (1) 73-85.39. McClure P et al. A randomized controlled comparison of stretching procedures for posterior shoulder tightness.JOSPT.2007;37:108-114.40. Muraki T et al.Lengthening of the pectoralis minor muscle during passive shoulder motions and stretching techniques: acadaveric biomechanical study.Phys Ther.2009;89:333-341.41. Ludewig PM et al. Relative balance of serratus anterior and upper trapezius muscle activity during push-up exercises.Am JSports Med.2004;32:484-493.42. Cools AM, Geerooms E, Van den Berghe DF, et al. Isokinetic scapular muscle performance in young elite gymnasts. J AthlTrain 2007;42:458–63.43. Warren Hammer The Scapular Assistance Test Dynamic Chiropractic – November 4, 2004, Vol. 22, Issue 2344. Cools AM et al. Rehabilitation of scapular muscle balance: which exercises to prescribe? Am J Sports Med.2007;35:1744-1751.45. de Mey K et al. Trapezius muscle timing during selected shoulder rehabilitation exercises.JOSPT.2009;39:743-752.46. De May K, Danneels L, Cagnie B, et al. Are kinetic chain rowing exercises relevant in shoulder and trunk injury preventiontraining? Br J Sports Med 2011; 45:320–1.47. Ben Kibler et al. Electromyographic Analysis of Specific Exercises for Scapular Control in Early Phases of Shoulder Rehabiliation Am. J. Sports Med. 2008; 36; 178948. McMullen J, Uhl TL. A kinetic chain approach for shoulder rehabilitation. J Athl Train 2000;35:329–37.49. Sciascia A, Cromwell R. Kinetic chain rehabilitation: a theoretical framework. Rehabil Res Pract 2012;2012:1–9.50. Bergman GJD, Winters JC, et al. Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder Dysfunction and Pain. Ann Int Med 2004 141:432-43951. Winters et al. Comparison of Physiotherapy, Manipulation and Corticosteroid Injection for Treating Shoulder Complaints inGeneral Practice. BMJ 199752. Sciascia AD, Thigpen CA, Namdari S, et al. Kinetic chain abnormalities in the athletic shoulder. Sports Med Arthrosc Rev2012;20:16–21.

Upper Crossed SyndromeEvaluation Deep Neck Flexor Endurance Test Neck Flexion Test Quadruped Rock Shoulder Abduction Screen Spinal Motion Palpation Standing Postural EvaluationManagement Soft Tissue STM- Levator STM- Pec Major STM- Upper TrapeziusManipulation/Mobilization Manipulation-Cervical and ThoracicPhase I exercises Cervical Retractions Deep Neck Flexion Levator Stretch Trapezius Stretch Corner Pectoral StretchPhase II exercises YTWL Scapular Depression Low Row Brugger with BandClinical Pearls Upper crossed syndrome has a direct impact on joint surfaces and oftenleads to self-perpetuating cycle of recurrent joint dysfunction, degenerationand changes in CNS motor control. Upper crossed syndrome creates apredictable pattern of joint dysfunctioninvolving the atlanto-occipital joint, C45, C7-T1, T4-5, and the glenohumeraljoint. Functional rehabilitation mustinclude proprioception and exercises to“groove new movement patterns”.“Upper Crossed Syndrome” aka “Cervical Crossed Syndrome” was first describedby Vladimir Janda in 1979 as a predictable pattern of alternating tightness andweakness involving the neck and shoulders. (1) The condition frequently contributes to neck and back pain and is associated with diagnoses ranging fromcervicogenic vertigo to rotator cuff pathology. (2)Upper quadrant muscular dysfunction does not occur at random, but rather, in apredictable pattern of altered posture as the body attempts to reach homeostasis. (3-5) The process typically begins when a muscle or muscle group is overusedin a certain direction and becomes shorter and tighter (adaptive shortening). Theantagonist muscles opposing this action are subject to prolonged stretch andtend to become longer and weaker (stretch weakness). (6)Janda classified muscles as either “postural” or “phasic.” Upper quadrant “postural” muscles (including theupper trapezius, levator, SCM,and pec major) are predisposed to tightness, while“phasic” muscles (includingthe rhomboid, serratus anterior, scalenes, and middle& lower trapezius) respondto dysfunction by becomingweaker. (1,4,7) The term “uppercrossed syndrome” was coinedbecause a line drawn to connect the tight muscles forms across with a second line drawnbetween the weak muscles. (8) ChiroUp 2015(See figure at right.)Upper crossed syndrome is a direct result of “flexor-dominated” postures (i.e. forward use of the arms and head). This process begins in the classroom as a childand progresses with age throughout the working years. (9) Most occupations,from computer operator to manual labor, are “flexor-dominated”. (10) Workstation users are particularly predisposed from prolonged static flexor dominatedpostures. (9,11) Sedentary lifestyles may contribute to the problem. (9) Nonmechanical factors like low self-esteem or depression may trigger upper crossedpostures. (12)Muscular balance is required for normal function, and muscular imbalance leadsto dysfunctional and inappropriate movement patterns. (13) This has a directimpact on joint surfaces and often leads to self-perpetuating cycle of recurrentjoint dysfunction. (i.e. subluxation) (4,14-16) Longstanding postural dysfunctionmay cause joint degeneration (1,4,17) and changes in CNS motor control. (4,16)Poor posture can negatively affect proprioception, balance, gait, and functional performance. (17) Poor posture has been associated with increased mortality rates in older adults. (17) Upper crossed syndrome places excessive stress on the upper thoracicregion and has been linked to T4 syndrome – a cause of chest pain and pseudo angina. (8)Upper crossed patients often complain of neck pain, interscapular pain, and headaches. (2) The condition is thought to contrib-

Upper Crossed Syndrome (Continued)ute to many upper body diagnoses, including cervical and thoracic intersegmental joint dysfunction, sprain/strain, discogenicpain, degeneration, vertigo, rotator cuff syndrome, thoracic outlet syndrome, costovertebral dysfunction, and TMD.Traditional “structural” diagnoses focuses on a “tissue” source for the patient’s symptoms (i.e. facet capsule, supraspinatus tendon, etc). Upper crossed syndrome is a “functional” diagnosis that requires identification of the underlying factors that contribute to structural lesions.Assessment for upper crossed syndrome begins with visual inspection. The ideal standing posture, when viewed from the side,is a plumb line passing through the ear, shoulder, greater trochanter, and slightly anterior to the lateral malleoli. (19,20) Posturalevaluation of patients with upper crossed syndrome will reveal a forward head posture with upper cervical extension, elevatedand protracted shoulders, scapular winging, and a thoracic hyperkyphosis. (8)Hypertonicity will be found in the upper trapezius, levator, pec major, and SCM. Palpation will often demonstrate tendernessor trigger point activity in the aforementioned muscles as well as the concurrently weak rhomboids, serratus anterior, middle &lower traps, scalenes and deep neck flexors.Functional assessment of neck flexion can be performed with a “Neck flexion test.” The test is performed when a supine positionis asked to lift their head several inches off of a table to look at their toes. The normal firing pattern for neck flexion is the longuscapitus, longus coli, SCM, and finally, anterior scalenes. The clinician observes for a “normal” movement pattern, which wouldbe initiated with a chin tuck and smooth reversal of the cervical lordosis. An “abnormal” screen would result in the chin movingforward into protraction from over compensation by the SCM. Abnormal neck movement suggests weakness of the deep neckflexors.The “Deep neck flexor endurance test” is another maneuver for assessing the deep neck flexors. This test starts with the patientin a supine, hooklying position. The patient performs chin retraction, then lifts their head an inch off of the table. The clinicianplaces their flat hand on the table below the patient’s occiput. If the patient’s head begins to lower or their anterior neck skinfolds separate, they are reminded to “tuck your chin and hold your head up.” The test is timed until the patient’s head touchesthe clinician’s hand for more than one second. The average endurance for men is about 40 seconds and 30 seconds for women.Those with neck pain average closer to 20 seconds. Low endurance suggests neck flexor weakness with a predisposition to overutilize the SCM, platysma, and hyoid- resulting in an upper crossed posture and neck pain. (21,22)Patients with upper crossed syndrome will often demonstrate abnormal shoulder abduction. The normal sequence for shoulderabduction is progressive firing of the supraspinatus, deltoid, infraspinatus, middle and lower trapezius, and contralateral quadratus lumborum. Patients with upper crossed syndrome frequently demonstrate early shoulder elevation (prior to 60 degreesof abduction) due to overactivity of the upper trapezius and levator scapula. (23,24)Patients with upper crossed syndrome often have weak scapular stabilizers (serratus anterior). Scapular stability may be assessed by the Quadruped rock test (aka Push up test). This assessment is performed by having the patient assume a quadrupedposition and slowly rock forward and backward while the clinician observes for signs of scapular winging.Joint dysfunction may arise secondary to muscular imbalance. (4,14-16) Janda noted that upper crossed syndrome creates apredictable pattern of joint dysfunction involving the atlanto-occipital joint, C4-5, C7-T1, T4-5, and the glenohumeral joint.(8,25,32)Management of upper crossed syndrome should first attempt to eliminate abnormal proprioceptive input through joint mobilization and myofascial release. (B) Rehab then progresses sequentially through stretching, strengthening, and finally, fascilitationof normal movement patterns. (4)Sherrington’s law of reciprocal inhibition states that when one muscle is hypertonic, its antagonist relaxes. (26,27) This law necessitates that hypertonic muscles be lengthened before embarking on the process of strength training. Stretching and myofascial release should be directed at the pectoral muscles, SCM, upper trapezius, and levator. Additionally, release of myofascialadhesions may be necessary in the rhomboids, serratus anterior, middle and lower traps, and scalenes. Manipulation may be

Upper Crossed Syndrome (Continued)necessary for restrictions in the cervical, thoracic, and shoulder regions. (32)Strengthening exercises should focus on the rhomboids, serratus anterior, middle & lower trapezius, and scalenes. Functional rehabilitation must include proprioception and exercises to “groove new movement patterns.” (28) Specific rehab exercises wouldinclude chin retraction, Brugger’s position, and scapular stabilization. (29-31) Patients should be counseled to reduce repetitivestress- including ergonomic workstation modification.References1. Page P., Frank C.C., Lardner R., Assessment and treatment of muscle imbalance: The Janda Approach 2010, Champaign, IL: Human Kinetics2. Hertling D & Kessler R. Management of Common Musculoskeletal Disorders: Physical Therapy Principles and Methods. FourthEdition. Lippincot Williams & Wilkins. 2006;150.3. Tunnell, P. Journal of Bodywork and Movement Therapies. 1996;1(1), 21.4. Janda, V., 1987. Muscles and motor control in low back pain: assessment and management. In: Twomey, L.T. (Ed.), PhysicalTherapy of the Low Back. Churchill Livingstone, New York, pp. 253–278.5. Janda Syndromes. www.jandaapproach.com accessed 8/19.20146. Kendall F, McCreary E, Et. al. Muscles. Testing and Function with Posture and Pain. Baltimore MD: Lippincott, Williams & Wilkins.2005;5th ed7. Moore, MK. Upper Crossed Syndrome And Its Relationship To Cervicogenic Headache. JMPT July/Aug. 2004;27,6:416.8. Janda compendium. Vol II. Minneapolis: O.P.T.P., p. 7-139. Thacker, D, Jameson J, Baker J, Divine J, Unfried A. Management Of Upper Cross Syndrome Through The Use Of Active ReleaseTechnique And Prescribed Exercises. Logan College Senior Research Paper10. Key, J., Clift, A., Condie, F., Et.al. Journal of Bodywork and Movement Therapies. 2008;12,113.11. Yoo, W., Yi, C., Kim, M. Effects of a ball-backrest chair on the muscles associated with upper cro

(Rotator Cuff Tendinopathy), ultimately leading to tear. This continuum is quite predictable. The renowned shoulder orthopedist, Dr Charles Neer, estimated that 95% of rotator cuff tears were from repetitive impingement (SAIS) rather than acute injury. Of those, 100% started with sc