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Shoulder Dykinesis|Muscles|Rehabilitation

This post was written by etoims on October 9, 2013
Posted Under: Upper Body Topics

In my professional experience, the most common cause of shoulder dykinesis is underlying cervical radiculopathies precipitated by acute or chronic repetitive trauma.  eToims can treat hyperactivity as well as hypoactivity of muscles.  I have found that upper trapezius is usually hyperactive while the mid and lower trap and latts dorsi are hypoactive and that there is weakness also in the whole kinetic chain with hip/leg and trunk weakness.  Advantages of eToims is that it can quickly diagnose and treat the muscles that are weak and hypoactive as well as those that are hyperactive throughout the whole body and both sides in a safe and efficacious manner in one session.  There are only arbitrary standards in exercises proposed by clinicians  as regards dose and duration of these exercises.  eToims  starts off the twitch induced exercise in the hyperactive muscles such as upper trapezius and adductor magnus and all muscles where trigger points are easily found.  This is followed by treatments to the hypoactive muscles such as the core spinal muscles and the Latissimus Dorsi and Gluteus maximus muscles. In addition, eToims it can be done repetitively throughout the day and every day to the same muscles without side effects.  The trigger points can be fatigued within a few seconds with acute problems.  With chronic problems, since the tissues are so tight that the electricity is unable to reach the trigger points well enough to fatigue, the exercise session can be as short as 10 minutes to the trigger points zone of a muscle or the entire treatment session for many muscles can be done over several hours if need be and the exercises can be repeated daily.

The following is excerpted from http://www.medscape.com/viewarticle/810159_5

Rehabilitation of Shoulder Dyskinesias

Many authors have suggested that forward head posture and increased thoracic kyphosis may contribute to scapular protraction and lead to adaptive shortening of postural muscles or muscular strength imbalances. A protracted scapular position may be associated with a narrowed subacromial space upright posture with increased subacromial space and a flexed thoracic spine and forward shoulder position alters scapular motion and results in diminished force output with elevation. Adaptive shortening of the pectoralis minor muscle has been identified as a contributor to abnormal scapular kinematics and implicated as a factor that may contribute to shoulder impingement syndrome.

What is Known and What is Not Known

Optimal rehabilitation of scapular dyskinesis requires addressing all of the causative factors that can create the dyskinesis and then restoring the balance of muscle forces that allow scapular position and motion.[30] Causative factors can be grouped into: (1) neurological factors include long thoracic, spinal accessory and dorsal scapular nerve palsies, evaluated by appropriate muscle testing, typical scapular position and diagnostic electromyography studies; (2) joint derangement factors include labral injury, glenohumeral instability, biceps tendinitis and A-C separations; (3) bone factors include clavicle and scapular fractures; (4) inflexibility factors include shoulder rotation tightness (GIRD and Total Range of Motion Deficit) and pectoralis minor inflexibility; muscular factors include lower trapezius and serratus anterior weakness, upper trapezius hyperactivity or scapular muscle detachment and  kinetic chain factors include hip/leg weakness and core weakness. The bone and joint internal derangement factors may require surgical repair before rehabilitation may be maximally effective. They may have to be healed before restoration of muscle performance.

Restoration of the scapular muscle force couples requires core strength and facilitation by kinetic chain activation. This establishes the proximal stability to prevent postural perturbation and force generation and maximises activation sequencing for the scapular retraction muscles. Once the stable proximal base is established, scapular rehabilitation can proceed along specific guidelines. An algorithm guideline has been proposed that is based on restoration of soft tissue inflexibilities and maximising muscle performance.

Several principles guide the progression through the algorithm. Acquisition of flexibility in the muscles and joints is usually required first because the tight muscles and capsule can inhibit strength activation. Also, muscles should be trained in sport or activity specific patterns. Research has demonstrated maximal scapular muscle activation when muscles are activated in functional patterns (vs isolated), when the muscles are activated in specific diagonal patterns using kinetic chain sequencing. Also, the activation is facilitated when the scapula is placed in a retracted position, thus increasing serratus anterior and lower trapezius activation as stabilisers in retraction Exercises should also emphasise lower trapezius and serratus anterior activation and reduce upper trapezius activation.

Using these principles, many rehabilitation interventions can be considered. A reasonable programme could start with standing low-load/low-activation exercises with the arm below shoulder level, to meaningfully activate the scapular retractors (>20% maximal voluntary isometric contraction) without putting the arm in an impingement position. It could then progress to prone and side-lying exercises that increase the load, but still emphasise lower trapezius and serratus anterior activation over upper trapezius activation. Additional loads and activations can be stimulated by integrating ipsilateral and contralateral kinetic chain activation and adding distal resistance. Final optimisation of activation can occur through weight training emphasising proper retraction and stabilisation.

Although the guidelines, principles and protocols may appear to be straightforward, the actual rehabilitation process is frequently complicated and prolonged. Many patients come into rehabilitation with well-established flexibility deficits, muscle activation patterns and compensatory motions so that overcoming these obstacles requires a prolonged rehabilitation course. The lower trapezius is frequently inhibited in activation, and specific effort may be required to ‘jump start’ it. Tightness, spasm and hyperactivity in the upper trapezius, pectoralis minor and latissimus dorsi are frequently associated with lower trapezius inhibition, and specific therapy should address these muscles. Finally, special attention should be paid to the glenohumeral joint because internal derangements can inhibit scapular muscle activation that may not correct until the internal derangement is corrected.

Biomechanical and clinical knowledge regarding the role of the scapula in shoulder function and dysfunction is growing, and the concepts regarding how to evaluate and treat scapular dyskinesis are evolving. There is enough information to emphasise the clinical implications for treating shoulder patients.

This consensus conference revealed that scapular involvement in almost all types of shoulder pathology may play an important, but as of now not a completely understood role in creating or exacerbating the shoulder dysfunction. Shoulder impingement symptoms in particular appear to be affected by scapular position and motion. Scapular dyskinesis is probably most aptly viewed as a potential impairment to optimum shoulder function and shoulder be evaluated and treated as part of the comprehensive treatment protocol.

Evaluation for scapular dyskinesis is primarily by clinical observation. A specific methodology has been identified with the tests showing to be reliable, but not specific. It can provide a good picture of the variety of alterations that can be associated with scapular dyskinesis.

Scapular rehabilitation protocols have been developed that have the potential to improve scapular muscle strength, alter scapular position and alter shoulder symptoms. They are best utilised within a comprehensive programme and should be implemented when all of the causative factors for scapular dyskinesis have been identified and addressed.

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