ASYMMETRICAL FORWARD SHOULDER POSTURE Evaluation and Treatment Considerations

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ASYMMETRICAL FORWARD SHOULDER POSTUREEvaluation
and Treatment Considerations

• Christopher Johnson, MPT MCMT

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Objectives

• Closely examine the asymmetrical forward shoulder
  posture (AFSP)
• Review musculoskeletal impairments associated
  with AFSP
• Discuss research pertaining to the AFSP
• Discuss evaluation strategies and become
  familiarized with interventions
• How does this change the way we treat?

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Bookhout Isaacs 2002
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Scapular Position
Thoracic Kyphosis
Apleys Scatch
Levator Scapulae
AFS
Tyler Test
IR _at_ 90 Abd
Neuromuscular Re-education
Biceps Brachii
Pectoralis Minor
Posterior GH Mobility
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Forward Shoulder Posture

• Posture and alignment of body segments are
  effected by mm shortening and weakness
• Upper quarter musculoskeletal dysfunction

Ayub 1991 Janda 1978 Penny et al. 1981 Travell
Simons 1984
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Upper Crossed Syndrome (Janda)

• Tight
• Upper Traps
• Levator Scap
• SCM
• Pectorals

• Weak
• Lower Traps
• Middle Traps
• Serratus Anter.
• Rhomboids

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Forward Shoulder Posture

• Scapular abduction elevation
• May also include
• Scapular winging
• Humeral IR
• Kendall McCreary 1983
• Diveta et al. 1990

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Forward Shoulder Posture

• Asymmetry rarely discussed!
• Associated with predictable impairments

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Posterior Shoulder Tightness

• Plays major role in controlling joint surface
  motion between humeral head and glenoid.
• Effect of tight capsular structures on normal
  shoulder range of motion has been well
  documented.

Harryman et al. JBJS 1990 OBrien et al. AJSM
1990 Terry et al. AJSM 1991 Warner et al. AJSM
1992 Tyler et al. AJSM 2000
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Posterior Shoulder Tightness

• Oblique GH translations occur when the capsule is
  asymmetrically tight
• Operative tightening of the posterior capsule
• Increased anterior translation with flexion and
  cross body movement
• Significant superior translation with GH flexion
• Decreased shoulder rotational ROM

Harryman et al. JBJS 1990
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Tests Measures
GH IR AROM
Forward Shoulder
Tyler Test
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Relationship Between Tyler Test Deficit and
Internal Rotation Deficit
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Summary

• Controls
• Arm dominance associated with
• FSP
• Loss of IR ROM
• Posterior shoulder tightness
• Dominant Arm Involvement
• Effects accentuated
• Nondominant Arm Involvement
• Effects absent

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Association Btw Internal Rotation ROM and
Posterior Shoulder Tightness
Tyler et al 2000 Compared absolute numbers
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Scapular Movement

• 3 movements
• Upward rotation
• IR/ER
• A-P tilt

Lukasiewicz et al JOSPT 1999
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Kiblers Scapular Dysfunctions
TYPE 1
TYPE 2
TYPE 3
Kibler et al JSES 2002
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• Two group comparison
• Compare scapular kinematics during arm elevation
  between individuals distinguished by pectoralis
  minor length
• 50 subjects without shoulder pain

Borstad JD Ludewig PM JOSPT 2005
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PMI Pectoralis Minor Index
PMI (Resting muscle length/Subject height) x 100
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Sagittal Plane Elevation
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Scapular Plane Elevation
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Coronal Plane Elevation
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• Nonrandomized 2 group post test design
• Five scapular kinematic variables assessed _at_ each
  arm position
• Groups
• 20 nonimpaired subjects
• 17 patients with impingement

Lukasiewicz et al JOSPT 1999
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Abnormal Scapular Position and Thoracic Kyphosis

• Weakened scapular mm in association with thoracic
  kyphosis (Fu et al. CORR 1991)
• Scapular protraction decreases the subacromial
  space (Solem-Bertoft et al CORR 1993)
• No increased lateral scapular translation with
  kyphosis but increased anterior tilt (Collin et
  al. 1992 )

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• Random allocation of subjects into placebo
  controlled crossover study
• Investigate effect of changing thoracic and
  scapular posture on shoulder flexion and scapular
  plane abduction ROM
• 60 asymptomatic subjects and 60 with SA
  impingement

Lewis et al JOSPT 2005
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Biceps Brachii
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Levator Scapulae
DOES TIGHTNESS LEAD TO INCREASED ANTERIOR TILT?
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Evaluation Tx Considerations

• Posture
• ROM Muscle Length
• Joint Integrity/Mobility
• Myofascial Trigger Points
• Neuromuscular Re-Education

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Postural Position

• Posterior View
• Lateral View
• Hands on Hips
• Supine

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Posterior View
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Supine
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Lateral View
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ROM Muscle Length
Active IR
Passive IR _at_ 90
Tyler Test
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Posterior GH Mobility
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Pectoralis Minor/Biceps Stretch
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Pre vs. Post Stretch
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Neuromuscular Re-ed
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Neuromuscular Re-ed
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Neuromuscular Re-ed
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Neuromuscular Re-ed
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Neuromuscular Re-ed
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Summary

• AFSP is common and typically associated with
  predictable impairments
• Dominant arm affected to a greater extent
• Requires thorough examination and treatment
• Additional research is needed!
• Esp in overhead athletes and various pathological
  states

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Thanks