The Throwing Athlete Biomechanics Function & Dysfunction
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1 The Throwing Athlete Biomechanics Function & Dysfunction R. Scott Cook, DO, FAOASM Director, St. Joseph Sports Medicine Fellowship Commonwealth Orthopaedic Associates Presentation Goals! Provide an understanding of normal Scapular Function and Motion.! Discuss the importance of the Scapula within the kinetic chain of the throwing athlete.! Describe clinical examination techniques for evaluation of scapular function.! Define and the role it plays in shoulder injury and pathology.! Scapular Osseous Components! Body, Spine, Coracoid Process, Acromion Process, Glenoid, Inferior Angle.! Arise from several ossification centers with varies stages of coalescence: Coracoid: 14-18yo Acromion: 19-20yo Inferior Angle: 18-20yo Glenoid Fossa: 20-25yo 1
2 ! Basic Anatomy: Scapula is enveloped by multiple muscular layers. Anterior Scapular Muscle Attachments:! Triceps! Biceps (Short and Long Heads)! Coracobrachialis! Subscapularis! Serratus Anterior! Pectoralis Minor! Omohyoid! Basic Anatomy: Posterior Scapular Muscle Attachments:! Triceps! Biceps (Long Head)! Omohyoid! Trapezis! Supraspinatous! Infraspinatous! Teres Major! Teres Minor! Levator Scapulae! Latissimus Dorsi! Deltoid! Rhomboideus Major and Minor! Scapular Bursae:! Infraserratus Bursa (Bursa Mucosa Serrata) Lies between Serratus Anterior and Chest Wall Inflammed = Inferior Angle Pain! Supraserratus Bursa (Bursa Mucosa Angulae Superioris Scapulae) Lies between Subscapularis and Serratus Anterior Inflammed = Superior Angle Pain! Scapulotrapezial Bursa Lies between Superomedial Scapula and Trapezius Contains the Spinal Accessory Nerve. 2
3 ! Scapular Anatomic Positioning at Rest:! Anteriorly Rotated (relative to trunk) approx 30! Medial Border Rotated Inferior Pole diverged 3-5 from Spine! Anteriorly Tilted 20 in sagittal plane! Scapulothoracic Anatomy & Function:! Scapular Postural Support Levator Scapulae & Upper Trapezius! Scapular Retraction Middle Trapezius & Rhomboids! Scapular Protraction Serratus Anterior! Upward Scapular Rotation Serratus Anterior & Trapezius! Scapular Elevation Upper Trapezius & Levator Scapulae! A. Scapular Posterior Tilting! B. Scapular Superior Rotation! C. Scapular External Rotation! D. Clavicular Elevation! E. Clavicular Protraction 3
4 ! Dynamic Anatomy:! Humeral movement in relation to Glenoid.! Glenohumeral Ligament and Labral static constraint on Humeral Translation.! Rotator Cuff dynamic constraint on Glenohumeral Motion. The Scapula is intimately involved in each one of these functions.! Glenohumeral Articulation! Scapula must continually move to maintain instant center of rotation.! Proper glenoid alignment optimizes function of articulations and rotator cuff to allow concentric GH-Motion.! Scaulothoracic positioning determines position and inclination of both Glenoid and Inferior Glenohumeral Ligament.! Improper alignment can lead to GH Instability.! Thoracic Wall Articulation! Scapular Retraction (external rotation) facilitate cocking position.! Scapular Lateral Protraction (internal rotation) allows acceleration.! Scapular Anterior Thoracic Translation allows maintenance of normal GH position and dissipation of deceleration forces. 4
5 ! Acromial Elevation! Serratus Anterior activation results in traction related superior acromial elevation.! Occurs during cocking and acceleration phases of throwing, and during arm elevation.! Allows for reduction of impingement and coracoacromial arch compression.! Kinetic Chain! Scapula serves as a link in Proximal-to-Distal sequencing of Velocity, Energy, and Forces of shoulder function. Generation, Summation, Transference Scapula serves as pivotal link of transference of large forces/high energy from lower body/core to the arm/ hand.! Also allows arm stabilization to absorb force loads through long-lever dynamics to reduce injury. Scapular Motion! Normal Scapular Dynamics:! Bilateral Posterior Tilting, External Rotation, & slight Superior Translation during elevation of arm.! Symmetrical motion patterns.! No prominent medial or superior scapular borders. 5
6 !! Alterations in STATIC scapular position and DYNAMIC scapular motion resulting in scapular asymmetry in gross postural assessment and function movement.! :! Affects normal Scapulohumeral Rhythm (SHR).! May lead to articular and/or soft tissue shoulder dysfunction.! May result in shoulder pathology and injury.! May result from injury causing inhibition of scapular stabilization. Nonspecific Response: No specific pattern of dyskinesis is associated with a specific shoulder diagnosis.! Contributing Factors! Bony Posture & Injury Increased Thoracic Kyphosis! Scapular Protraction! Acromial Depression Clavicle Fractures AC Joint Injury! Disrupt normal progression of scapular rotation 6
7 ! Contributing Factors! Muscle Function Alteration Nerve injury! Long Thoracic Nerve Serratus Anterior! Spinal Accessory Nerve Trapezius Muscle Inhibition/Weakness! Common in Glenohumeral Pathology! Nonspecific response to shoulder pain 68% RC Abnormalities 94% Labral Tears 100% GH Instability! Contributing Factors Contracture/Inflexibility! Pectoralis Minor/SH-Biceps! Anterior Tilted Scapula! GIRD Wind-Up Effect! Glenoid and Scapula pulled in forward-inferior direction! May result in protraction during arm-adducted position! Associated Shoulder Pathology:! Subacromial Impingement! Glenohumeral Instability! Glenoid Labral Injury! Rotator Cuff Injury 7
8 Assessing! Clinical Examination Kinetic Chain Evaluation:! Leg/Trunk Muscle Strength! Lumbar Lordotic Posture! Pelvic Alignment! Iliac Rotations, SI Instability/Dysfunction! Hip ROM! Thoracic Alignment/Posture! Thoracic Kyphosis, Scoliosis! Cervical Posture! Cervical Lordosis Assessing! Clinical Examination Examine patient from behind with arms at rest at sides. Examine Scapular Motion as arms are elevated and lowered within scapular plane. Examine Scapular Motion as arms are elevated and lowered within the sagittal plane. Types of! Type I! Prominence of Inferior Medial Scapular Angle.! Primarily abnormal rotation around a transverse axis.! Results in excessive anterior scapular tilt.! Type II! Prominence of entire Medial Scapular Border.! Results in abnormal rotation around a vertical axis.! Associated with excessive scapular internal rotation.! Type III! Prominence of Superior Scapular Border.! Results in excessive superior scapular translation.! Type IV! Normal, Symmetrical scapular motion. 8
9 Assessing! Observational Clinical Assessment! 4-Type Method versus Yes/No Method! Easily available! Wide variance of Inter-Rater Reliability (4-Type) Sensitivity 10%-54%; Specificity 62%-94% (Yes/No) Sensitivity 74%-78%; Specificity 31%-38%! Limited assessment of multiple-plane asymmetries! 3D EM Kinematic Analysis! Lab-based; limited availability! Allows for multiple-plane assessment! Detected asymmetry may not be clinically relevant Uhl et al; Arthroscopy, 25(11); 2009 Assessing! Yes/No Method! Improved Inter-Rater Agreement (79%) Allows consideration beyond a single-plane of motion PPV = 74%! Displays Sensitivity (76%) & Specificity (35%) similar to other clinical shoulder exam tests. Clinical SLAP tests: Mean Sensitivity 57%; Specificity 41% Clinical Instability tests: Mean Sensitivity 71%; Specificity 38% Clinical Impingement tests: Mean Sensitivity 68%; Specificity 49%! Prevalence of Scapular Asymmetry! 71%-78% (3D Kinematics) of population at large! Symptomatic vs. Asymptomatic Additional Factors:! Ligamentous Laxity, Muscle Imbalance, Side Dominance! Plane of Assessment may determine clinical relevance Forward Flexion Motion Asymmetry increased in Symptomatic (54%) versus Asymptomatic (14%) patients.! Increased Serratus Anterior activity 9
10 Effects of! Loss of Retraction/Protraction Retraction Loss! stable Cocking point or base for arm elevation.! Impingement as scapula rotates inferior and anterior. Protraction Loss! deceleration forces in GH Joint.! Functional Glenoid Anteversion. shear stresses on anterior stabilizing structures. posterior impingement Effects of! Loss of Superior Elevation Decreased Acromial Elevation! Predisposes Subacromial Impingement.! Inhibition of Serratus Anterior and Lower Trapezius. Effects of! Loss of Kinetic Chain Function Disruption of transferal of lower extremity and core forces to the upper extremity.! Strength and Energy Use! Acceleration Velocity 10
11 References! Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: Spectrum of pathology. Part I: Pathoanatomy and biomechanics. Arthroscopy 2003;19: ! Fleisig et al. Biomechanics of overhand throwing with implications for injuries. Sports Med 1996;21: ! Gaunche et al. The synergistic action of the capsule and the shoulder muscles. Am J Sports Med 1995;23: ! Glousman et al. Dynamic EMG analysis of the throwing shoulder with glenohumeral instability. J Bone Joint Surg Am 1988;70: ! Kibler WB, McMullen J. Scapular dyskinesis and its relation to shoulder pain. J Am Acad Orthop Surg 2003;11: ! Kibler WB. Evaluation and diagnosis of scapulothoracic problems in the athlete. Sports Med and Arthro Rev 2000;8: ! Kibler WB. Role of the scapula in the overhead throwing motion. Contmp Orthop 1991;22: ! Kibler WB. The role of the scapula in athletic shoulder function. Am J Sports Med 1998;26: ! Kibler et al. Qualitative clinical evaluation of scapular dysfunction. A reliability study. J Shoulder Elbow Surg 2002;11: ! Laudner et al. Scapular dysfunction in throwers with pathologic internal impingement. J Orthop Sports Phys Ther 2006;36: ! McQuade KJ, Dawson J, Smidt GL. Scapulothoracic muscle fatigue associated with alterations in scapulohumeral rhythm kinematics during maximum resistive shoulder elevation. J Orthop Sports Phys Ther 1998;28:74-80.! Myers JB, et al. Glenohumeral range of motion deficits and posterior shoulder tightness in throwers with pathologic internal impingement. Am J Sports Med 2006;34: ! Oyama et al. Asymmetric resting scapular posture in healthy overhead athletes. J Athl Train 2008;43: ! Uhl et al. Evaluation of clinical assessment methods for scapular dyskinesis. Arthroscopy 2009;25:
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