Infraspinatus strength assessment before and after scapular muscles rehabilitation in professional volleyball players with scapular dyskinesis
We previously had a post about the effectiveness of the scapular assistance test in clinical patients with sub-acromial impingement. Another similar clinical test that is commonly used to determine if the scapula is contributing to rotator cuff weakness is the scapular retraction test. This test is performed by first testing external rotation rotator cuff strength with a manual muscle test (MMT) then the scapula is manually retracted and stabilized with the tester’s forearm and the MMT is repeated. If the strength increases with the manual retraction then the test is positive for weak and deficit scapular stabilizers. This study recruited 31 professional volleyball players with pain and weakness of the infraspinatus. MRIs were performed to rule out any internal soft tissue damage of the shoulder. Scapular dyskinesis was categorized for all participants using methods described by Kibler (https://www.ncbi.nlm.nih.gov/pubmed/12469078). Following the initial evaluation, a 6 month scapular specific rehabilitation protocol was administered on all participants. This protocol focused on reestablishing a normal balance between the upper trapezius, middle and lower trapezius, as well as the serratus anterior. Infraspinatus strength testing with and without scapular retraction was preformed at baseline, 3 and 6 month post rehabilitation, using a hand held dynamometer. Pain was measured using a visual analog scale at each evaluation. They found that at both 3 and 6 months infraspinatus strength increased for the MMT without scapular retraction. They also found that when comparing the difference in strength between the MMT with and without retraction the difference significantly decreased at both 3 and 6 months. Pain scores also decreased at 3 and 6 months compared to baseline.
This study found that volleyball players with scapular dyskinesis can improve infraspinatus strength and shoulder pain after 3 and 6 months of a scapular-specific rehabilitation program. This demonstrates the importance of the scapula in providing a stable base of support for the infraspinatus and that the scapular retraction test can successfully identify rotator cuff weakness related to scapular instability. This is an easy screening tool that can be used by clinicians to identify patients with strength deficits that are associated with scapular instability and not necessarily the rotator cuff. Focusing on reestablishing the normal force couple between the upper, middle, and lower trapezius as well as the serratus anterior can improve the overall stability of the glenohumeral joint by allowing the cuff to conduct its primary function of maintaining the humeral head within the glenoid fossa. The primary goal in any scapular program should be to improve neuromuscular control and not increases in strength or endurance (potential secondary goals). Increases in strength and endurance will follow if proper neuromuscular control is enforced during rehabilitation. What is everyone’s experience with the retraction test and the use of scapular neuromuscular control programs for improving shoulder function and pain in overhead athletes?
Written by: Stephen Thomas
Reviewed by: Jeff Driban
I'm not a big fan of the MMT based retraction test because of the subjectivity, however I whole heartedly agree with scapular retraction providing a stable base to allow improved shoulder function and decreased shoulder pain.
In my experience I have treated several football players (lineman) that have experienced acute or chronic shoulder issues during play. Asking them to push and drive a sled was a daunting task and aggravating in nature. Simply by cueing them to retract and maintain retraction through contact and drive, most looked at me amazed after driving the sled either without pain or markedly decreased pain.
In my opinion the use of scapular neuromuscular control programs for improving shoulder function and pain in ALL athletes is the foundation to a successful rehabilitation program. I honestly believe that for far too long rehabilitation and treatment has been hinged on stabilizing the humeral head in the glenoid. (I have always heard the softball on a golf tee analogy). In my brief golf career, how many times are you going to place your ball on that tee if it keeps falling off before you find a new spot for the tee.
I was taught in my UG program by a great instructor that the key to the shoulder was the rotator cuff. Eight quick years later I'm a firm believer and would argue the key to the shoulder is the scapula because of its role in positioning the glenoid. If you want long lasting resolution, find an optimal space to place that tee, your drive will thank you!
I don't use the Scap Retraction test in its true form but do utilize scapular retraction when assessing painful ROM, almost like a postural check before an activity/movement.
When assessing shoulder dysfunction/treatment I almost always start with the scapula. Favoring Neuromuscular control over strengthening for a good part of it. Working both bilaterally and unilaterally.
Luckily in the Philly area there clinicians putting out great research/data that have helped to form the foundation of how I address the scapula. Along with all the other reseach/data that has been done over the years.
I agree with Tommy comments in regards to the importance of the scapula.
Nice post Steve
Tommy thanks for posting. I couldn't agree more and I think your addition to the long taught "golf tee analogy" is great! Good stuff.
Tom also thanks for posting. It seems to be a common trend so far that the scapular retraction test is not a favorite among clinicians. You bring up a good point that I commonly stress which is rehabilitating bilaterally. I feel by activating the scapular muscles bilaterally you get more of an enhanced contraction not to mention the classic "cross education effect" to further improve strength and endurance.
The instance you referred to with the football players and scapular positioning during play was interesting.
Did/Do you ever use taping (kinesio or otherwise) to re-inforce this positioning during functional activty or with rehab??
I have not used any taping techniques in these circumstances and haven't really used taping for these types of rehabilitations. The only thing I've done in addition to the cue and several minutes of instruction on the sled is wrap the student-athlete's shoulder with an Ace Wrap similar to the Sully shoulder brace to help provide support. Even with the shoulder wrapped I had received the same results as my original post in terms of decreasing pain to ensure it wasn't the wrap that was helping the athlete.
To be honest with you I am very remedial in terms of my knowledge with the kinesiotape. I am a huge fan of it and have gotten great results in terms of patellofemoral pain and (I can't stomach saying the word) shin splints. Would very much welcome if you have any pearls of wisdom in that regard with the shoulder!
I only tape for patella and plantar fascial problems.
I know colleagues that use it for shoulder/elbow sx but I can't say that I use it. I only have used tape to try to check excessive scap protraction and reinforce posture, but not on a consistent basis.
Usually like to have the athlete/patient learn to check and correct thru Neuromuscular training.
Funny, I was looking for a pearl from you.
Anyone out there in SMR that has any experience/success in this area, bring on some comments.
The only pearl I can throw your way regarding scapular control and postural awareness that I provide for my athletes is this…
I have the athlete place their hands behind their head. Next focus on keeping the upper trap as quiet as possible. Now focus their attention on the degree of retraction that naturally occurs from this position. I ask them to hold their shoulder blades still and bring their arms to their side. This position then serves as their starting point for EVERY exercise we perform.
My athletes, being in school all day, I also have them perform this simple task as the bell rings to begin each class and try to hold that position as long into the period as possible. Repeat next class!
I have found this is a great quick and easy to remember method to get my athletes back to "attention" when they are not performing an exercise correctly….
Thats all i got for right now, if I think of anything I will be sure to throw it your way.
I am always looking for alternative scap stabilization exercises and was wondering if you have access to the rehab protocol used in the study for additional suggestions or variations. i welcome all input!!
Thanks for the post Tommy
I work in a busy PT setting and I think the cueing on scapular positioning is something of upmost importance and lots of time overlooked.
Likewise with athletes, this postural re-setting can be used t/o day with the sedentary population. Like it, esp the teaching of quietting the UT! thanks.
The position you described I have seen with unilateral table top and wall scapular exercises, except the opposite UE is maintained in the position (hand behind the head) for scapular retraction.
When I initiate RTC therabands I will occasionally have the patient keep their uninvolved hand behind their back, like if it was in their back pocket or keep in the position mentioned above, but I like the use of having the patient/athlete learn and maintain on their own thru your cueing, I will add that onto my progression.
Lisamarie thanks for posting. You can email Jeff Driban for a copy of the protocol. You can get to his email via his blogger profile (noted on the right column). He has a contact link on his blogger profile. Thanks again for your interest.
I'm a little late to the party, but i wanted to weigh in. @Tom and @Tommy, have either of you guys utilized either the S4 or the posture shirt for your athletes? The S4 is an awesome option for achieving fairly consistent retraction throughout exercises.
The posture shirt is less overbearing and definitely more suited to somebody that is looking to maintain the postural gains that they may have already made. That's not say a person couldn't use the posture shirt alone, but it might be harder to attain the solid scapulae foundation. It would also be a great option
for your linemen, or any other athlete for that matter, to utilize while training. It's light weight and can get under just about anything. It's a decent alternative and you don't have to worry about the same issues as you do with taping.
I used the S4 while at Temple and had great results with it. I've seen it shown off at the NATA Exhibitor Hall. You can track both items down at http://www.aligned.com. The endorsements range from Ben Kibler, to former pro athletes to ATCs. They have great stuff.