Annelies Maenhout

Rehabilitation of scapular dyskinesis: from the office worker to the elite overhead athlete

The scapula functions as a bridge between the shoulder complex and the cervical spine and plays a very important role in providing both mobility and stability of the neck/shoulder region. The association between abnormal scapular positions and motions and glenohumeral joint pathology has been well established in the literature, whereas studies investigating the relationship between neck pain and scapular dysfunction have only recently begun to emerge. Although several authors have emphasised the relevance of restoring normal scapular kinematics through exercise and manual therapy techniques, overall scapular rehabilitation guidelines decent for both patients with shoulder pain as well as patients with neck problems are lacking. The purpose of this paper is to provide a science-based clinical reasoning algorithm with practical guidelines for the rehabilitation of scapular dyskinesis in patients with chronic complaints in the upper quadrant.

Electromyographic analysis of knee push up plus variations: what is the influence of the kinetic chain on scapular muscle activity?

Objective First, to look for appropriate closed kinetic chain exercises to restore intramuscular imbalance between upper trapezius (UT) and serratus anterior (SA) in overhead athletes. Second, to determine the influence of using diagonal pattern muscle recruitment during knee push up plus (KPP) exercises on scapular electromyographic activity. Design Single group repeated-measures design. Setting Controlled laboratory study. Participants Thirty-two physically active individuals in good general health who did not have a history of neck and/or shoulder injury or surgery nor participated in high-level overhead sports or performed upper limb strength training for more than 5 h/week. Interventions Subjects performed the standard KPP and six variations. Main outcome measurements Electromyographic activity of the three trapezius parts and the SA. Results Four exercises with a low UT/SA can be selected for rehabilitation of intramuscular balance: standard KPP, KPP with homolateral leg extension, KPP with a wobble board and homolateral leg extension and one-handed KPP. The use of a wobble board during KPP exercises and performance on one hand has no influence on SA electromyographic activity. Heterolateral leg extension during KPP stimulates lower trapezius activity, whereas homolateral leg extension stimulates SA activity. Conclusions In case of intramuscular scapular imbalance, some exercises are preferable over others because of their low UT/SA ratio. The use of a kinetic chain approach during KPP exercises influences scapular muscle activity.

Quantifying Acromiohumeral Distance in Overhead Athletes With Glenohumeral Internal Rotation Loss and the Influence of a Stretching Program

Background: Loss of internal rotation range of motion (ROM) on the dominant side is well documented in athletes performing overhead sports activity. This altered motion pattern has been shown to change glenohumeral and scapular kinematics. This could compromise the subacromial space and explain the association between glenohumeral internal rotation deficit (GIRD) and subacromial impingement. Purpose: First, to quantify acromiohumeral distance (AHD) and compare between the dominant and nondominant side in overhead athletes with GIRD of more than 15°. Second, to investigate the effect of a sleeper stretch program on ROM and AHD. Study Design: Controlled laboratory study. Methods: Range of motion was measured with a digital inclinometer and AHD was measured with ultrasound in 62 overhead athletes with GIRD (>15°) at baseline. Differences between sides were analyzed. Athletes were randomly allocated to the stretch (n = 30) or control group (n = 32). The stretch group performed a 6-week sleeper stretch program on the dominant side. Change of range of motion and AHD were measured and analyzed in both groups after 6 weeks. Results: The dominant side showed a significant internal rotation deficit (−24.7° ± 6.3°) and horizontal adduction deficit (−11.8° ± 7.4°) and the dominant side AHD was significantly smaller with the arm at neutral (−0.4 ± 0.6 mm) and at 45° (−0.5 ± 0.8 mm) and 60° (−0.6 ± 0.7 mm) of active abduction compared with the nondominant side. After stretching, significant increase of internal rotation (+13.5° ± 0.8°), horizontal adduction (+10.6° ± 0.9°) ROM and AHD (+0.5 to +0.6mm) was observed at the dominant side of the stretch group compared with prestretching measurements. No significant change of AHD was seen in the nondominant side of the stretch group and in both sides of the control group. Conclusion: The AHD, a 2-dimensional measure for subacromial space, was found to be smaller on the dominant side in athletes with GIRD and was found to increase after a 6-week sleeper stretch program. Clinical Relevance: These findings might provide insight into the relation between GIRD and subacromial impingement but future studies are needed to determine clinical implications.

Scapular-Muscle Performance: Two Training Programs in Adolescent Swimmers

CONTEXT Swimming requires well-balanced scapular-muscle performance. An additional strength-training program for the shoulders is pursued by swimmers, but whether these muscle-training programs need to be generic or specific for endurance or strength is unknown. OBJECTIVE To evaluate isokinetic scapular-muscle performance in a population of adolescent swimmers and to compare the results of training programs designed for strength or muscle endurance. DESIGN Controlled laboratory study. SETTING University human research laboratory. PATIENTS OR OTHER PARTICIPANTS Eighteen adolescent swimmers. INTERVENTION(S) Each participant pursued a 12-week scapular-training program designed to improve either muscle strength or muscle endurance. MAIN OUTCOME MEASURE(S) Bilateral peak force, fatigue index, and protraction/retraction strength ratios before and after the scapular-training program. RESULTS Scapular protraction/retraction ratios were slightly higher than 1 (dominant side  =  1.08, nondominant side  =  1.25, P  =  .006). Side-to-side differences in retraction strength were apparent both before and after the training program (P  =  .03 and P  = .05, respectively). After the training program, maximal protraction (P < .05) and retraction (P < .01) strength improved on the nondominant side. Peak force and fatigue index were not different between the training groups. The fatigue indexes for protraction on both sides (P < .05) and retraction on the nondominant side (P  =  .009) were higher after the training program. CONCLUSIONS We describe the scapular-muscle characteristics of a group of adolescent swimmers. Both muscle-strength and muscle-endurance programs improved absolute muscle strength. Neither of the strength programs had a positive effect on scapular-muscle endurance. Our results may be valuable for coaches and physiotherapists when they are designing exercise programs for swimmers.

Consensus for physiotherapy for shoulder pain

PurposeShoulder pain is a common disorder. Despite growing evidence of the importance of physiotherapy, in particular active exercise therapy, little data is available to guide treatment. The aim of this project was to contribute to the development of an internationally accepted assessment and treatment algorithm for patients with shoulder pain.MethodsNine physiotherapists with expertise in the treatment of shoulder dysfunction met in Sweden 2012 to begin the process of developing a treatment algorithm. A questionnaire was completed prior to the meeting to guide discussions. Virtual conferences were thereafter the platform to reach consensus.ResultsConsensus was achieved on a clinical reasoning algorithm to guide the assessment and treatment for patients presenting with local shoulder pain, without significant passive range of motion deficits and no symptoms or signs of instability. The algorithm emphasises that physiotherapy treatment decisions should be based on physical assessment findings and not structural pathology, that active exercises should be the primary treatment approach, and that regular re-assessment is performed to ensure that all clinical features contributing to the presenting shoulder pain are addressed. Consensus was also achieved on a set of guiding principles for implementing exercise therapy for shoulder pain, namely, a limited number of exercises, performed with appropriate scapulo-humeral coordination and humeral head alignment, in a graduated manner without provoking the presenting shoulder pain.ConclusionThe assessment and treatment algorithm presented could contribute to a more formal, extensive process aimed at achieving international agreement on an algorithm to guide physiotherapy treatment for shoulder pain.

Prevention of shoulder injuries in overhead athletes: a science-based approach.

The shoulder is at high risk for injury during overhead sports, in particular in throwing or hitting activities, such as baseball, tennis, handball, and volleyball. In order to create a scientific basis for the prevention of recurrent injuries in overhead athletes, four steps need to be undertaken: (1) risk factors for injury and re-injury need to be defined; (2) established risk factors may be used as return-to-play criteria, with cut-off values based on normative databases; (3) these variables need to be measured using reliable, valid assessment tools and procedures; and (4) preventative training programs need to be designed and implemented into the training program of the athlete in order to prevent re-injury. In general, three risk factors have been defined that may form the basis for recommendations for the prevention of recurrent injury and return to play after injury: glenohumeral internal-rotation deficit (GIRD); rotator cuff strength, in particular the strength of the external rotators; and scapular dyskinesis, in particular scapular position and strength.

The impact of rotator cuff tendinopathy on proprioception, measuring force sensation

BACKGROUND The impact of rotator cuff tendinopathy and related impingement on proprioception is not well understood. Numerous quantitative and qualitative changes in shoulder muscles have been shown in patients with rotator cuff tendinopathy. These findings suggest that control of force might be affected. This investigation wants to evaluate force sensation, a submodality of proprioception, in patients with rotator cuff tendinopathy. METHODS Thirty-six patients with rotator cuff tendinopathy and 30 matched healthy subjects performed force reproduction tests to isometric external and internal rotation to investigate how accurately they could reproduce a fixed target (50% MVC). Relative error, constant error, and force steadiness were calculated to evaluate respectively magnitude of error made during the test, direction of this error (overshoot or undershoot), and fluctuations of produced forces. RESULTS Patients significantly overshoot the target (mean, 6.04% of target) while healthy subjects underestimate the target (mean, -5.76% of target). Relative error and force steadiness are similar in patients with rotator cuff tendinopathy and healthy subjects. Force reproduction tests, as executed in this study, were found to be highly reliable (ICC 0.849 and 0.909). Errors were significantly larger during external rotation tests, compared to internal rotation. CONCLUSION Patients overestimate the target during force reproduction tests. This should be taken into account in the rehabilitation of patients with rotator cuff tendinopathy; however, precision of force sensation and steadiness of force exertion remains unaltered. This might indicate that control of muscle force is preserved.

Acromiohumeral Distance and 3-Dimensional Scapular Position Change After Overhead Muscle Fatigue

CONTEXT Muscle fatigue due to repetitive and prolonged overhead sports activity is considered an important factor contributing to impingement-related rotator cuff pathologic conditions in overhead athletes. The evidence on scapular and glenohumeral kinematic changes after fatigue is contradicting and prohibits conclusions about how shoulder muscle fatigue affects acromiohumeral distance. OBJECTIVE To investigate the effect of a fatigue protocol resembling overhead sports activity on acromiohumeral distance and 3-dimensional scapular position in overhead athletes. DESIGN Cross-sectional study. SETTING Institutional laboratory. PATIENTS OR OTHER PARTICIPANTS A total of 29 healthy recreational overhead athletes (14 men, 15 women; age = 22.23 ± 2.82 years, height = 178.3 ± 7.8 cm, mass = 71.6 ± 9.5 kg). INTERVENTION(S) The athletes were tested before and after a shoulder muscle-fatiguing protocol. MAIN OUTCOME MEASURE(S) Acromiohumeral distance was measured using ultrasound, and scapular position was determined with an electromagnetic motion-tracking system. Both measurements were performed at 3 elevation positions (0°, 45°, and 60° of abduction). We used a 3-factor mixed model for data analysis. RESULTS After fatigue, the acromiohumeral distance increased when the upper extremity was actively positioned at 45° (Δ = 0.78 ± 0.24 mm, P = .002) or 60° (Δ = 0.58 ± 0.23 mm, P = .02) of abduction. Scapular position changed after fatigue to a more externally rotated position at 45° (Δ = 4.97° ± 1.13°, P < .001) and 60° (Δ = 4.61° ± 1.90°, P = .001) of abduction, a more upwardly rotated position at 45° (Δ = 6.10° ± 1.30°, P < .001) and 60° (Δ = 7.20° ± 1.65°, P < .001) of abduction, and a more posteriorly tilted position at 0°, 45°, and 60° of abduction (Δ = 1.98° ± 0.41°, P < .001). CONCLUSIONS After a fatiguing protocol, we found changes in acromiohumeral distance and scapular position that corresponded with an impingement-sparing situation.

Sonographic evaluation of the acromiohumeral distance in elite and recreational female overhead athletes.

Objective:To compare the acromiohumeral distance (AHD) and the change of this distance during abduction between the dominant and nondominant shoulders of female overhead athletes and to compare AHD between elite and recreational female athletes. Design:Case–control study. Setting:Laboratory, institutional. Independent Variables:“Side” (dominant and nondominant), “group” (elite and recreational athletes), and “degree of abduction” (0, 45, and 60 degrees). Participants:Sixty-two female overhead athletes participated in this study: 29 elite handball players and 33 recreational overhead athletes of different sports disciplines (volleyball, water polo, squash, and badminton). Main Outcome Measures:Acromiohumeral distance was measured at 3 positions of abduction using ultrasound: at 0, 45, and 60 degrees of abduction. Results:Acromiohumeral distance measurements showed good test–retest reliability (intraclass correlation coefficients between 0.88 and 0.92). In all overhead athletes, the AHD was significantly larger on the dominant side compared with the nondominant side, at all positions of abduction (mean difference = 0.94 ± 0.18 mm). Significant reduction of the AHD during abduction occurred relative to the initial size at 0 degree of abduction, at both sides. When comparing elite and recreational athletes, the AHD was significantly larger in elite athletes (mean difference = 0.92 ± 0.47 mm). Moreover, significantly less reduction occurred during the first degrees of abduction (0-45 degrees) in elite athletes (9.37% ± 2.17% reduction) compared with the recreational athletes (17.68% ± 2.03% reduction). Conclusions:The AHD is larger on the dominant side compared with the nondominant side and in elite female athletes compared with recreational female athletes. Moreover, less reduction of the AHD occurs in the elite athlete group during the first 45 degrees of abduction.

Does the application of kinesiotape change scapular kinematics in healthy female handball players

Elastic taping is widely used in sports medicine for correcting functional alignment and muscle recruitment. However, evidence regarding its influence on scapular dynamic positioning is scarce. This study aimed to investigate the effect of a specific kinesiotaping method on scapular kinematics in female elite handball players without shoulder complaints. 25 athletes (18.0±1.5 years) active in the highest national division were recruited. All subjects received an elastic adhesive tape (K-active tape©) with the purpose to correct scapular position. 3-dimensional scapular motion measurements were performed (Fastrak®) during humeral elevation in the sagittal, frontal and scapular plane. The results showed that taping has a moderate to large effect (Cohens d>0.7) towards scapular posterior tilting, in all 3 planes of humeral movement and for all angles of elevation (mean posteriorizing effect of 4.23 °, 3.23 ° and 4.33 ° respectively for elevation in the sagittal, frontal and scapular plane, p<0.001). In addition, taping also moderately increased the scapular upward rotation at 30 °, 60 ° and 90 ° of humeral abduction (mean increase of 2.90 °, Cohens d>0.7). Together these results suggest that kinesiotape application causes positive changes in scapular motion. This could support its use in sports medicine for preventing shoulder problems in overhead athletes.