Transcript Carpal Tunnel Syndrome

Jared Ricotta PA-S
10/29/2011
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Scapular dyskinesis is an alteration in the
normal position or motion of the scapula
during coupled scapulohumeral movements
(1).
Commonly seen in injuries involving the
shoulder joint that lead to the improper usage
of muscles attached to the scapula due to
physical inhibition and/or pain (i.e. rotator cuff
tear, shoulder impingement, bursitis, arthritis).
Can be identified and classified by specific
physical examination and diagnostic
procedures
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John-O is a 39 year old right hand dominant gentleman presented to The
Orthopedic Group for first time evaluation.
Chief complaint of right shoulder pain and upper back pain for 15
months.
Pain began after falling into a hole while working in his garage, which
resulted in hitting his elbow, axially loading his shoulder, but with a
slight flexion pushing his shoulder posteriorly.
Symptoms began as pain over the upper back, the lateral acromion region
down to the lateral bicep, which improved to some degree, but over the
past 8 months has failed to improve any further.
Difficulty with overhead movements and internal rotation. Feels as
though there is a mechanical block, and just cannot move arm any
further.
Pain average is 5-6/10 and on aggravation 10/10.
Has tried massage, Tylenol and ice to no avail.
Cannot sleep on right side and feels like shoulder is going to pop out of
joint when going through range of motion.
John-O is a motorcycle builder and fishing guide and would like to be
able to ‘skip a rock again’.
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PMH
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Medications:
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Denies Diabetes, Heart Disease, Asthma, COPD, Cancer,
Neurologic Disease, Thyroid Disease, Kidney Disease, Bleeding
Disorders or Psychological Disorders. Parents alive and well.
Social History
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Adenoids removed in 1977
PMH/Family history
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Men’s Daily Multivitamin
Past surgical history
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None
Occasional alcohol use. No nicotine or illicit drug use. Eats well
balanced organic meals and exercises daily which is inhibited by
his condition.
Patient has no known drug allergies.
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Pain over upper back and over right shoulder, .
No numbness or tingling distally, no loss of
sensation, pain is non-radiating in nature, no
neck injury or pain, no erythema, ecchymosis,
masses, lesions, and no prior history of trauma
to the shoulder.
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Vital Signs:
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130/82 | 98.2 F | pulse 72 | respirations 16 | weight 162 lbs | height 5’8”.
Musculoskeletal:
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Right shoulder lateral winging as well as upward and lateral rotation of
the medial border of the scapula. Atrophy of the infraspinatus and
supraspinatus musculature on right. Tender along medial paraspinal
muscle complex, supra and infraspinatus fossa, and trapezius. Pulses 2+/4
in all extremities. Neurologically, strength 5/5, reflexes 2+/4, and
sensation intact to light touch in bilateral uppers.
Scapular winging exaggerated by chest press maneuver.
Scapular Assist Test (SAT) increases range of abduction but is still painful.
Positive Neer’s at end ROM, Positive Hawkins, equivocal empty can test,
and significantly positive O’Brien’s test.
Shoulder does not drop fully, apprehension when lying down testing
shoulder external rotation with shoulder at 90 degrees flexion and pain
upon axial loading of shoulder.
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Scapular Assistance Test (SAT)
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Examiner stabilizes the upper scapular border and
assists upward rotation of the inferomedial border as
the arm is abducted
Positive Test= relief of symptoms of impingement,
clicking, or rotator cuff weakness
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Scapular dyskinesis
Posterior labral tear
Posterior rotator cuff tear
Neurological insult
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Alterations in scapular motion and position
Non-specific response to a painful condition in the shoulder rather
than a specific response to a certain glenohumeral pathology
Result from alterations in:
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bony stabilizers
muscle patterns
dynamic muscle stabilizers
Multiple causative factors:
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Proximally-
 Muscle weakness/imbalance
 Nerve injury
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Distally- (as in our case)
 AC joint injury
 Superior labral tears
 Rotator cuff injury
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Pertinent History
Physical Exam
Diagnostic Procedures
Non-Pathologic X-Ray
 Negative EMG
 Minor Musculoskeletal Ultrasound Pathology
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Scapular dyskinesis treatment is directed at
managing underlying causes and restoring
normal scapular muscle activation patterns by
using a daily strengthening and re-education
program for all the scapular stabilizer muscles
(3).
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1)Physical Therapy to correct scapular pathology
2) Physical Therapy to correct shoulder pathology
and/or Surgery to correct shoulder pathology
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Altered kinematics of the scapula fall into 3
clinically recognizable patterns known as
Kibler’s Classification:
Type I- Inferior medial scapular border
prominence = labral pathology
Type II- Medial scapular border prominence =
labral pathology (today’s case)
Type III- Prominence of the superomedial
border of scapula= impingement and rotator cuff
lesions
Type I
Type II
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1) W. Ben Kibler, M.D. and John McMullen, A.T.C.
Scapular Dyskinesis and Its Relation to Shoulder
Pain. The American Academy of Orthopedic Surgeons
Journal. Vol. 11, No. 2, March/April 2003, 142-151.
2) Ramirez-Del Toro, Jose, M.D. Physiatrist. The
Orthopedic Group, Pittsburgh, PA. Oral interview
8/29/11.
3) Stephen S. Burkhart, M.D., Craig D. Morgan,
M.D., and W. Ben Kibler, M.D. The Disabled
Throwing Shoulder: Spectrum of Pathology Part
III: The SICK Scapula, Scapular Dyskinesis, the
Kinetic Chain, and Rehabilitation. The Journal of
Arthroscopic and Related Surgery, Vol. 19, No. 6, JulyAugust), 2003: 641-661.