Prevalence and Factors Associated with Shoulder Complex Function (SCF) Among the Elderly in Private Physiotherapy Clinic in Klang Valley, Malaysia

@#Introduction: Shoulder problems have been a challenge among the aging population. Although reports surfaced on factors affecting shoulder dysfunction, however, such studies in relation to other factors like neck pain (NP) factor are limited especially among the elderly in the urban population. This study investigated the prevalence and factors associated with shoulder complex dysfunction among the outpatient elderly attending private physiotherapy clinics. Methods: A total of 75 elderly aged ≥ 60 years old from four private physiotherapy clinics were recruited by simple random sampling method. The elderly were evaluated using the QuickDASH questionnaire to assess shoulder complex dysfunctions and NP scale. Results: A total of 92% of participants have shoulder complex dysfunction. A positive correlation of NP to shoulder complex dysfunction ( r (75) = 0.83, p<.001) with significant associations of sex ( z= -2.549, p=0.011), smoking ( z= -2.388, p=0.017), lifestyle ( z= -5.780, p=0.000), hypertension ( z= -2.808, p=0.005), osteoarthritis ( z= -2.966, p=0.003), and NP scale ( z= -2.173, p=0.031). The predicting factor of shoulder complex dysfunction is sex (β = 0.156, t (74) = 2.240, p= 0.028) and NP scale (β = 0.704, t (74) = 7.853, p= 0.000). Conclusion: There is a high prevalence of shoulder complex dysfunction among the outpatient elderly attending private physiotherapy clinics with a predicting associating factor of sex and NP.

Reliability of Shoulder Helical Axes During Intransitive and Transitive Upper Limb Tasks.

Shoulder complex stability can be estimated in vivo through the analysis of helical axes (HAs) dispersion during upper limb movements. The study aimed at investigating test-retest reliability of shoulder HAs dispersion parameters during upper limb tasks. Twenty healthy volunteers performed 2 intransitive (shoulder flexion and rotation) and one transitive (combing) tasks with the dominant and nondominant upper limbs during 2 recording sessions at 1-week distance. Kinematics was detected through an optoelectronic system. Mean distance and mean angle (MA) were adopted as HAs dispersion indexes. Reliability was excellent for mean distance (intraclass correlation coefficient [ICC]: .91) and MA (ICC: .92) during dominant flexion, and good for MA (ICC: .90) during nondominant flexion. Moderate reliability was found for HAs parameters during rotation (ICCs from .70 to .59), except for MA during dominant rotation where reliability was poor. Reliability was good for mean distance (ICC: .83) and moderate for MA (ICC: .67) during the dominant combing task, whereas no reliability was found during the nondominant combing task. HAs dispersion parameters revealed high reliability during simple intransitive tasks with the dominant limb. Reliability decreased with the increase in task complexity due to the increase in movement variability. HAs dispersion technique could be used to assess shoulder complex stability in patients after rehabilitation or surgery.

Reliability and Concurrent Validity of Smartphone Clinometer Application for Measuring Scapular Rotations in Subjects With and Without Shoulder Pain.

CONTEXT:   Clinical assessment of scapular motion is obscured by a lack of clinically accessible and feasible angular measurement tools. This study evaluates the reliability and validity of the smartphone "Clinometer" app in measuring scapular upward rotation (UR) and anteroposterior tilt. DESIGN: Psychometric analysis. METHODS: We recruited 57 participants-10 with and 47 without shoulder pain. Two physical therapists consecutively measured both scapular movements using the Clinometer app at the arm by the side (rest), 30°, 60°, 90°, and 120° of humeral elevation in the scapular plane; one therapist measured again after 2 days. For evaluating concurrent validity, we compared the Clinometer scores with those measured using an electromagnetic motion capture system in 10 healthy participants. Intraclass correlation coefficients (ICC) with standard error of measurement (SEM) and minimal detectable difference at 90% confidence intervals (MDD90) were calculated. Concurrent validity was evaluated using repeated-measures analysis of variance followed by post hoc testing with Tukey-Kramer test (P < .05). RESULTS: We observed good intrarater reliability (ICC: UR = .76-.85, tilt = .69-.9; SEM: 2.2°-3.5°; MDD90: ∼5°-8°) and moderate to good interrater reliability (ICC: UR = .66-.78, tilt = .66-.76; SEM: 3.6°-8°; MDD90: ∼9°-18°) for both rotations. The Clinometer scores for UR were comparable to electromagnetic motion capture system at all angles except 90° (difference ∼8°); for scapular tilt, the scores were comparable only at rest and 30° elevation. CONCLUSION: The Clinometer app is reliable and valid for measuring scapular UR throughout and for scapular tilt at lower humeral elevation angles. The MDD90 values for scapular rotations computed in this study can be helpful in rehabilitation planning and future research.

Evaluation of the range of motion of scapulothoracic, acromioclavicular and sternoclavicular joints: State of the art.

The scapulothoracic, acromioclavicular and sternoclavicular joints play a fundamental role in the shoulder function. Shoulder complex kinematics have been studied with different methods using: goniometers, 2 static radiographs, 3D motion analyzers (invasive or noninvasive) and digital inclinometers. Goniometers have been used traditionally to assess scapular rotation in relation to the thorax. The intrinsic limit of multiple static two-dimensional shoulder radiographs is the attempt of describing in two what is occurring in three dimensions. Technology innovations have led to the development of the 3D shoulder complex kinematics analysis ETS (Electromagnetic tracking systems) using sensors (invasive bone-pin markers or noninvasive skin surface marker) stitched to the scapula/clavicula, thorax, and humerus. Despite being uncomfortable, invasive 3D motion cortical pins analyzers still represent the current gold standard for tracking shoulder complex kinematics. Therefore, access to three-dimensional biomechanical instrumentations for collecting kinematic data represents an active problem for many physicians. A precise, easy to use and low-cost non-invasive method able to draw and analyze the kinematics of the shoulder complex has not been developed yet. Further researches are necessary to design a new non-invasive method able to draw and analyze the kinematics of the scapula and the whole shoulder complex, precisely.

Proximal to distal sequencing impacts on maximum shoulder joint angles and the risk of impingement in baseball pitching involving a scapular independent thoracohumeral model.

BACKGROUND: Hyperangulation of the scapulohumeral joint due to poor coordination of the scapula during throwing motion is claimed to be a major cause of internal impingement in baseball pitchers. However, evidence of injurious scapular kinematics is lacking, particularly regarding how hyperangularion actually occurs in full-effort pitching. The purpose of this study was to describe sequential scapular motions involved in attaining maximum joint angles during pitching and the implications for internal impingement in elite baseball pitchers. METHODS: An electromagnetic goniometer system computed kinematics for pelvis, thorax, scapulae, arms, and forearms during baseball pitching in 72 pitchers. Internal impingement risk was assessed based on kinematic characteristics of internal impingement quantified in a cadaveric study. RESULTS: The pelvis, thorax, and scapula rotated in the proximal-to-distal sequence. Large forearm layback observed near the end of the cocking phase (182 ± 27°) was achieved with a submaximal scapulohumeral external rotation (98 ± 14°). In the next 0.027 ± 0.007 s, forward thoracic rotation and then scapular rotation caused increased scapulohumeral external rotation to a maximum of 113 ± 14°. Here, humeral horizontal adduction and scapula protraction occurred simultaneously preventing the humerus from lagging further behind the scapula. Only one participant reached critical hyperangulation beyond which internal impingement was reported to occur. CONCLUSION: Most elite pitchers safely attained the fully cocked position, yet off-timed recoiling of scapular protraction caused hyperangulation in full-effort pitching. Therefore, proximal-distal sequencing between the scapula and humerus should be evaluated to lessen the risk of internal impingement in baseball pitchers.

Comparison of the Effects of Isometric Horizontal Abduction on Shoulder Muscle Activity During Wall Push-Up Plus and Wall Slide in Individuals With Scapular Winging.

CONTEXT: Wall push-up plus (WPP) and wall slide (WS) are commonly prescribed in early rehabilitation to increase serratus anterior (SA) muscle activity. For individuals with scapular winging (SW), synergistic muscles such as upper trapezius (UT) and pectoralis major (PM) may compensate for weak SA during scapular movement. However, no studies have applied isometric horizontal abduction (IHA) during WS in individuals with SW nor have compared it with WPP with IHA. OBJECTIVES: This study compared the effects of IHA on shoulder muscle activity during WPP and WS exercises in individuals with SW. DESIGN: Cross-sectional study; 2-way repeated-measures analysis of variance was used to assess the statistical significance of observed differences in SA, UT, PM, lower trapezius (LT), and infraspinatus (IS) muscle activities. SETTING: Research laboratory. PATIENTS: We recruited 30 individuals with SW comprising 20 men and 10 women. INTERVENTIONS: The individuals performed WPP and WS exercises with and without IHA using Thera-Band. MAIN OUTCOME MEASURES: Surface electromyography was used to measure muscle activity of the SA, UT, PM, LT, and IS during the isometric phase of WPP and WS. Maximal voluntary isometric contractions were recorded to normalize electromyographic data. RESULTS: There was no significant interaction between IHA application and exercise type for any of the shoulder muscles. IHA application increased SA (P = .008), UT (P = .001), LT (P = .009), and IS (P = .000) activities and decreased PM (P = .001) activity compared with those without IHA. WS exercises elicited higher PM (P = .017) and LT (P = .011) activities than WPP. CONCLUSION: WPP and WS with IHA may be effective in increasing the muscle activities of shoulder stabilizers and preventing overactivation of PM activity. WPP may be recommended for individuals with overactivated PM, whereas WS may be used to increase LT activity.

Assessment of three-dimensional rotation of the shoulder complex and scapulohumeral rhythm during sagittal movement.

BACKGROUND: Due to the influence of spinal and respiratory movements, it is difficult to accurately measure the range of motion of each joint. OBJECTIVE: To conduct a three-dimensional (3D) measurement of each joint in the shoulder complex in different postures in the sagittal plane of the upper extremity. METHODS: Thirteen healthy adults with no history of shoulder surgery for trauma or chronic pain were enrolled in the present study. The computed tomography (CT) imaging data of the shoulder complex were acquired in four postures via the reconstruction and alignment of 3D images. The angles of the postural changes were measured, and rotation vectors were used for descriptions and statistical analyses. RESULTS: There was a statistical difference in the rotation angles between the dominant and non-dominant sides of the sternoclavicular joint when the posture changed from a resting position to a posterior inferior position. During the postural change from a resting position to a horizontal position, the regression coefficient (ß) of the humerothoracic joint to the sternoclavicular joint was 0.191, and the ß of the humerothoracic joint to the glenohumeral joint was 0.621. During the postural change from the horizontal position to the rear upper position, the ß of the humerothoracic joint to the sternoclavicular joint was 0.316, and the ß of the humerothoracic joint to the glenohumeral joint was 0.845. During the postural change from the resting position to the rear lower position, the ß of the humerothoracic joint to the glenohumeral joint was 0.991. CONCLUSION: The application of the image alignment technique enabled the direct and accurate measurement of the bony structures of the shoulder joint. The helical approach accurately described the scapulohumeral rhythm during 3D motion. There was a scapulohumeral rhythm of the shoulder complex during 3D composite sagittal movement, with different ratios for different joints and postures.

Evaluating the Influence of Gravity on Shoulder Strength Measures Assessed via Handheld Dynamometry.

CONTEXT: Handheld dynamometry is a feasible, reliable, and cost-effective method for assessing shoulder strength. One limitation to this tool is the lack of standardized testing protocols and specified shoulder strength test positions. Although it is recommended that strength tests be performed in a gravity-eliminated position, this may not always be a feasible or practical testing protocol. There is limited research on the influence of gravity on strength measures; to our knowledge, no study has compared handheld dynamometry shoulder strength assessments based on body position and gravity. Therefore, the purpose of this study was to compare shoulder flexion, extension, and abduction strength assessed via handheld dynamometry between a gravity-eliminated and a gravity-influenced test position. DESIGN: This study was a comparison of shoulder strength based on test position. The test position was the independent variable, and the dependent variables were shoulder flexion, extension, and abduction strength. METHODS: Supine (gravity-eliminated) and seated (gravity-influenced) strength measures were assessed in 20 healthy adults (19.4 [1.2] y) on the dominant arm. Paired t tests were used to determine differences between body positions for each test. Significance was accepted at P ≤ .05. RESULTS: There were no differences between supine and seated flexion and extension measures. Absolute supine shoulder abduction scores (152.5 [58.4] N) were significantly higher than seated scores (139.9 [55.6] N). CONCLUSIONS: Findings show that gravity should be considered when using handheld dynamometry scores as indicators of abductor shoulder strength and function.

Mirror Cross-Exercise on a Kinetic Chain Approach Improves Throwing Performance in Professional Volleyball Athletes With Scapular Dyskinesis.

CONTEXT: Volleyball players have shown to be at an increased risk of developing scapular dyskinesis. The kinetic chain exercise approach has gained a lot of attention because of its claims to provide an improved motor control and scapular kinematics. A form of cross exercise, known as mirror therapy, may enhance the effects of a kinetic chain exercise approach in throwing performance. OBJECTIVE: To examine the effects of mirror cross exercise (MCE), based on a kinetic chain exercise approach in the throwing performance of volleyball athletes with scapular dyskinesis. DESIGN: Randomized controlled trial. SETTING: Biomechanics laboratory. METHODS: 39 volleyball players with scapular dyskinesis were randomly allocated into 3 groups. The first group completed a 6-week kinetic chain approach (KCA group), the second group completed a kinetic chain exercise approach program in addition to MCE group, and the control group followed only their regular training program. Before and after delivering both interventions, throwing accuracy, speed, and force were determined while measuring the ground reaction forces of the drive leg during throwing. Two-way mixed analysis of variance investigated the effects of intervention and time and their interaction. RESULTS: The results showed intervention × time statistically significant interactions for throwing accuracy, speed, and force for the MCE and the KCA groups. Over the 6-week training period, the MCE and the KCA groups showed significant improvements in throwing accuracy (P < .01) and speed (P < .01), while the ground reaction forces did not change (P > .05). Throwing force increased significantly in the MCE group (P = .01). Between-group comparison showed statistically significant improvements in the throwing accuracy for the MCE and KCA groups against the control group (P < .01) at posttesting. The MCE demonstrated superior results over the KCA in the aforementioned measures. CONCLUSIONS: This study suggests that the addition of MCE in a KCA program enhances energy transfer throughout the distal and proximal segments, thus improving kinetic chain recruitment and potentially preventing shoulder pathology.

Motor Control Evaluation as a Significant Component in Upper Limb Function Assessment in Female Breast Cancer Patients after Mastectomy.

Breast cancer is the most prevalent malignancy among women. Conservative and operative treatment methods are associated with a risk of side effects pertaining to the shoulder complex. The surgery complications including chronic pain, upper limb and chest lymphedema, range of motion limitations, and motor control deficiencies may lead to upper limb function impairment and affect the quality of life negatively. Twenty-three women were examined in the tested group and twenty-two women in the control group. The motor control was assessed with dissociation tests as defined by Comerford and Mottram. In order to assess patient-perceived upper limb disability, the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire was used. The test of glenohumeral (GH) abduction control in frontal plane and in scapular plane and medial rotation control outcomes were found to be statistically significant. It pertains to both: Comparison between groups and analysis within the tested group-body sides comparison. The DASH questionnaire results analysis indicates that there was a higher degree of subjectively perceived disability of upper limb in the tested group. Surgical interventions in the breast cancer treatment and other medical procedures affect the level of motor control and perceived disability of upper limb negatively in this group of patients. Movement faults are statistically more prevalent in the tested group. Movement faults are more prevalent on the operated side in the tested group.

The Effects of Instrument-Assisted Soft Tissue Mobilization, Tissue Flossing, and Kinesiology Taping on Shoulder Functional Capacities in Amateur Athletes.

CONTEXT: Instrument-assisted soft tissue mobilization (IASTM), tissue flossing, and kinesiology taping are increasingly popular treatments among athletes for improving functional performance, despite limited evidence for their efficacy. OBJECTIVE: Previous research regarding the efficacy of soft tissues and neuromuscular techniques on improving functional capacity of shoulder joints in athletes has yielded conflicting results. We examined the immediate and short-term effects of IASTM, flossing, and kinesiology taping on the functional capacities of amateur athletes' shoulders. DESIGN: Randomized controlled study. SETTING: Clinical assessment laboratory. PARTICIPANTS: Eighty amateur overhead athletes (mean [SD]: age = 23.03 [1.89]; weight = 78.36 [5.32]; height = 1.77 [.11]). INTERVENTIONS: We randomly assigned participants to 4 research sub-groups in which they received the following treatments on their dominant shoulders: IASTM (n = 20), flossing (n = 20), both IASTM and flossing (n = 20), and kinesiology tape (n = 20). Nondominant shoulders served as controls. MAIN OUTCOME MEASURE: We evaluated participants-before, immediately after, and 45 minutes after the therapeutic interventions-with the following tests: internal and external shoulder rotation range of motion, isokinetic strength and total work, the functional throwing performance index, and the one-arm seated shot put throw performance. RESULTS: All therapeutic interventions significantly improved the strength and functional performance of the dominant shoulder in comparison with the control (P < .005) immediately after and 45 minutes after the treatment. The IASTM led to significantly greater improvement in shoulder internal rotation than kinesiology taping immediately after (P = .049) and 45 minutes after the treatment (P = .049). We observed no significant differences between the other treatment interventions (P > .05). CONCLUSION: Findings from the current study support the use of novel soft tissue and neuromuscular techniques for the immediate and short-term improvement of the shoulder functional capacities in amateur overhead athletes.

Dispersion of shoulder helical axes during upper limb movements after muscle fatigue.

Shoulder complex control of motion is influenced by neuromuscular function and can be quantified through the analysis of helical axes (HAs) dispersion. Muscle fatigue is a variable able to influence neuromuscular control, altering muscle activation timing and proprioception. The aim of the study was to describe shoulder complex HAs dispersion after muscle fatigue during upper limb movements of young healthy subjects. Thirty healthy right-handed volunteers (age 23.2 ± 2.6 years) were asked to perform a test made up of 15 humerothoracic flexion and rotation movements using both upper limbs in two different recording sessions. After each session, muscles of the tested movement were fatigued in isometric condition at dominant side. After fatigue, subjects repeated the test. Kinematics was recorded by an optoelectronic system and HAs dispersion was computed using Mean Distance (MD) and Mean Angle (MA) for the entire Range of Motion (RoM) and in portions of RoM. After fatigue of shoulder flexion muscles, greater MD (p = 0.001) and MA (p = 0.019) were found on the dominant side. After fatigue of shoulder rotation muscles, greater MD and MA were found on the dominant (p = 0.002 for MD; p = 0.047 for MA) and non-dominant (p = 0.038 for MD; p = 0.019 for MA) sides. Independently of fatigue, greater MA was found in portions of RoM with higher external resistance torque in flexion and rotation tasks. Muscle fatigue increases shoulder complex HAs dispersion, probably due to alteration in neuromuscular control. This data should be considered when exercise involving upper arms are proposed to subjects undergoing fatigue.

The Long-Term Effectiveness of Trigger Point Dry Needling and Exercise for Individuals With Shoulder Pain: A Critically Appraised Topic.

Clinical Scenario: Shoulder pain is a very common symptom encountered in outpatient physical therapy practice. In addition to therapeutic exercise and manual therapy interventions, trigger point dry needling (TDN) has emerged as a possible treatment option for reducing shoulder pain and improving function. Dry needling consists of inserting a thin stainless-steel filament into a myofascial trigger point with the intention of eliciting a local twitch response of the muscle. It is theorized that this twitch response results in reduced muscle tension and can aid in reduced pain and disability. To this point, multiple studies have found TDN to be effective at reducing pain and improving function in the short-term, but the long-term outcomes remain unknown. Clinical Question: Does the addition of TDN to an exercise program result in better long-term pain intensity and disability reduction in patients with shoulder pain? Summary of Findings: Improvement in long-term pain and function can be expected regardless of the addition of TDN to an evidence-based exercise program for patients with shoulder pain. Clinical Bottom Line: Either TDN or an evidence-based therapeutic exercise program elicits improved long-term pain and disability reduction in patients with shoulder pain, which suggests that clinicians can confidently use either approach with their patients. Strength of Recommendation: Strong evidence (level 2 evidence with PEDro scores >8/10) suggesting that TDN does not outperform therapeutic exercise regarding long-term pain reduction.

A Modified Kinematic Model of Shoulder Complex Based on Vicon Motion Capturing System: Generalized GH Joint with Floating Centre.

Due to the complex coupling motion of shoulder mechanism, only a small amount of quantitative information is available in the existing literature, although various kinematic models of the shoulder complex have been proposed. This study focused on the specific motion coupling relationship between glenohumeral (GH) joint center displacement variable quantity relative to the thorax coordinate system and humeral elevation angle to describe the shoulder complex. The mechanism model of shoulder complex was proposed with an algorithm designed. Subsequently, twelve healthy subjects performed right arm raising, lowering, as well as raising and lowering (RAL) movements in sixteen elevation planes, and the motion information of the markers attached to the thorax, scapula, and humerus was captured by using Vicon motion capturing system. Then, experimental data was processed and the generalized GH joint with floating center was quantized. Simultaneously, different coupling characteristics were detected during humerus raising as well as lowering movements. The motion coupling relationships in different phases were acquired, and a modified kinematic model was established, with the description of overall motion characteristics of shoulder complex validated by comparing the results with a prior kinematic model from literature, showing enough accuracy for the design of upper limb rehabilitation robots.

Mechanisms of traumatic injury to the shoulder girdle in the Australian Football League.

OBJECTIVE: To investigate mechanisms of shoulder girdle injuries and their impact on players from the Australian Football League (AFL). DESIGN: Retrospective video analysis. METHODS: Two experienced sports physiotherapists (>10years) examined video footage of shoulder complex injuries that occurred in the 2015 premiership season. Information obtained from video footage included activity prior to injury; mechanism of injury; arm, head and neck position and point of body contact at the time of injury. Player demographics and injury characteristics were obtained from club and media data. RESULTS: The most common mechanism of injury was lateral contact (34.6%) followed by hyperflexion/ abduction of the shoulder (19.2%). Glenohumeral joint (GHJ) dislocations and subluxations were the most frequent diagnosis for all mechanisms of injury, and occurred in a variety of shoulder positions. Over 80% of injuries occurred with the arm below 100° of shoulder flexion or abduction. The most common activity prior to injury was 'ball in dispute' (34.6%). Lateral contact injuries had the highest overall severity (two-thirds of players missed >3 games) and over 50% of shoulder injuries required surgery. Players missed on average 5.1 season games due to shoulder injury. CONCLUSION: The lateral contact mechanism was the most common and severe mechanism of shoulder injury. Improved understanding of shoulder girdle injury mechanisms can help guide the use of preventative strategies and injury management programs in elite AFL players.

Dispersion of helical axes during shoulder movements in young and elderly subjects.

The shoulder complex (SC) consists of joints with little congruence and its active and passive structures ensure its stability. Stability of the SC rotation centre during upper arm movements can be estimated through the analysis of Helical Axes (HAs) dispersion. The aim of this study was to describe shoulder HAs dispersion during upper limb movements performed with dominant and non-dominant arms by young and elderly subjects. Forty subjects participated in the study (20 young: age 24.8 ±â€¯2.8 years and 20 elderly: age 71.7 ±â€¯6.3 years). Subjects were asked to perform four cycles of 15 rotations, flexions, elevations and abductions with one arm at a time at constant speed. Reflective markers were placed on participants' arms and trunk in order to detect movements and the HAs dispersion with an optoelectronic system. Mean Distance (MD) from the HAs barycenter and Mean Angle (MA) were used as HAs dispersion indexes. Young subjects showed significant lower MD compared to the elderly during all motion ranges of rotation, flexion and elevation (p < 0.001). Moreover, the MD was lower in the dominant arm compared to the contralateral for rotation (p = 0.049) and flexion (p = 0.019). The results may be due to joint degeneration described in elderly subjects and differences in neuromuscular control of SC stability.

EFFICACY OF REFLEXIVE NEUROMUSCULAR STABILIZATION DURING TREATMENT OF SCAPULAR DYSKINESIA IN AN OVERHEAD ATHLETE: A CASE REPORT.

BACKGROUND AND PURPOSE: Shoulder injuries are common amongst overhead athletes. Dysfunctional motor patterns (scapular dyskinesis) may be the cause or result. Improperly treated, they can sideline athletes or reduce quality of life. Current treatment protocols are lengthy and may result in recurrence. Individualization of treatment is key. Functional tests, like the Selective Functional Movement Assessment (SFMA), help discern and properly identify dysfunction, paving the way for interventions like reflexive neuromuscular stabilization (RNS). RNS focuses on restoring proper motor control and may positively influence healing. The purpose of this case report is to describe an evaluation and treatment strategy for scapular dysfunction in an overhead athlete. CASE DESCRIPTION: The subject was a 16-year-old, multi-sport athlete in the high school setting. He presented with upper back pain during his sophomore baseball season. Clinical findings upon examination included but were not limited to irregular scapular positioning as compared bilaterally, dysfunctional scapular movement patterns, soft tissue muscular irritability and loss of glenohumeral (GH) ROM in internal and external rotation, flexion and abduction. Intervention consisted of a combination of positional release therapy and reflexive neuromuscular stabilization aided by some traditional therapeutic modalities. OUTCOMES: The combination of conservative treatments and RNS provided relief of the subject's symptoms in a shorter time frame, three treatments over the course of six days, than just utilizing traditional protocols. The utilization of the paired treatments resulted in diminished pain, restored ROM and improvement in perceived fluidity (speed and stability) of motion as observed by the clinician. A minimal clinically important difference (MCID) was reported on the disablement of the physically active scale (DPAs) on all follow-up treatments as well as on the numeric pain rating scale (NPRS) after the first and second treatments. The minimal detectable change (MDC) requirement was met on the patient specific functional scale (PSFS) prior to the second and third treatment. The activities measured with the PSFS were: GH flexion, GH abduction and throwing a baseball. DISCUSSION: In this case report, the use of the SFMA along with a traditional orthopedic examination allowed for proper identification and location of the dysfunctional motor patterns. The coupling of a traditional modality like the moist heat pack, with PRT and RNS proved to be a beneficial treatment combination for this subject as it provided a clinically meaningful resolution of his condition. Even though current literature suggests that treatment for scapular dysfunction is comprised of three phases over the course of ten weeks, clinicians should focus on the individualization of the treatment, possibly utilizing novel interventions like PRT and RNS. LEVEL OF EVIDENCE: 4 Case Report.

Biomechanics of posterior shoulder instability - current knowledge and literature review.

Posterior instability of the shoulder is a rare condition and represents about 10% of shoulder instability. It has become more frequently recognized in the last year, even though it is more difficult to diagnose than anterior shoulder instability. As this form of shoulder pathology is somewhat rare, biomechanical knowledge is limited. The purpose of our study was to perform an extensive literature search, including PubMed and Medline, and to give an overview of the current knowledge on the biomechanics of posterior shoulder instability. The PubMed/Medline databases were utilized, and all articles related to posterior shoulder instability and biomechanics were included to form a comprehensive compilation of current knowledge. A total of 93 articles were deemed relevant according to our inclusion and exclusion criteria. As expected with any newly acknowledged pathology, biomechanical studies on posterior shoulder instability remain limited in the literature. Current biomechanical models are performed in a static manner, which limits their translation for explaining a dynamic pathology. Newer models should incorporate dynamic stabilization of both the rotator cuff and scapulothoracic joint. There is a current lack of knowledge with regards to the pathomechanism of posterior shoulder instability, with no consensus on appropriate treatment regimens. Further investigation is therefore required at both basic science and clinical levels.

Isokinetic assessment of shoulder complex strength in adolescent elite synchronized swimmers.

Children and adolescent participation in sport has increased in recent years. Synchronized swimming requires correct muscle balance in the shoulder complex. The purpose of this study was to establish isokinetic strength profiles and peak torque ratios of shoulder internal and external rotator muscles in a female high-level synchronized swimming team. Twenty-six adolescent female high-level synchronized swimmers, aged 12-14, participated in this study. Maximal bilateral shoulder concentric external and internal rotation force was measured at 60°/s (5 repetitions) and 180°/s (15 repetitions). The isokinetic concentric strength generated by the internal rotator muscles was significantly higher (p < 0.05) than by the external rotators in both limbs and at both velocities. Significant bilateral differences in the external rotation (ER):internal rotation (IR) strength ratio were noted at 60°/s. Isokinetic assessment is essential in sports medicine, since it is the only test capable of diagnosing any shoulder strength deficit.

Scapular kinematics during scaption in competitive swimmers.

This study aimed (1) to describe and compare scapular kinematics between three groups of swimmers of different levels and a group of non-swimmers, and (2) to assess whether swimming practice alters the asymmetries in scapular kinematics between the dominant and non-dominant sides, both during unilateral arm raising and lowering in the scapular plane. Scapular kinematics were assessed bilaterally during arm raising and lowering in the scapular plane using an electromagnetic system in 42 healthy males, which were split into four groups: control (n = 11), adolescent elite swimmers (n = 11), adult elite swimmers (n = 10), and club-level adult swimmers (n = 10). One-Way ANOVA SPM(t) on two repeated measures showed that the three groups of swimmers had more protracted shoulder between 30° and 90° of arm raising and lowering (p < .001). The three groups of swimmers presented no bilateral difference in scapular upward rotation, while the dominant scapula was more upwardly rotated than the non-dominant one between 74° and 104° of arm elevation in the control group (p < .001). The scapula of adult elite swimmers was more internally rotated between 67° and 116° of humeral elevation during arm raising, and between 81° and 54° during arm lowering in comparison to the other swimming and control groups (p ≤ .02), who presented similar scapular positioning in internal rotation. In conclusion, the findings of the study pointed out that swimming practice generated protracted shoulders and removed bilateral differences in scapular upward rotation during scaption, while accumulation of swimming practice at elite level enlarged scapular internal rotation.