02/12/2025
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โ ๐ฆด ๐๐๐๐ฉ๐ฎ๐ฅ๐จ๐ก๐ฎ๐ฆ๐๐ซ๐๐ฅ ๐๐ก๐ฒ๐ญ๐ก๐ฆ: ๐๐ง๐๐๐ซ๐ฌ๐ญ๐๐ง๐๐ข๐ง๐ ๐ญ๐ก๐ ๐๐จ๐จ๐ซ๐๐ข๐ง๐๐ญ๐๐ ๐๐จ๐ญ๐ข๐จ๐ง ๐จ๐ ๐ญ๐ก๐ ๐๐ก๐จ๐ฎ๐ฅ๐๐๐ซ ๐๐จ๐ฆ๐ฉ๐ฅ๐๐ฑ
โ The scapulohumeral rhythm, also referred to as the glenohumeral rhythm, is a fundamental concept in shoulder biomechanics. First published by Codman in the 1930s, it defines the kinematic interaction between the scapula and the humerus. This precise interplay is essential for the optimal function of the shoulder joint.
โ ๐งฉ ๐๐ก๐ ๐๐ง๐๐ญ๐จ๐ฆ๐ฒ ๐จ๐ ๐๐จ๐จ๐ซ๐๐ข๐ง๐๐ญ๐๐ ๐๐จ๐ฏ๐๐ฆ๐๐ง๐ญ
โ The shoulder complex achieves coordinated arm elevation through the involvement of four primary articulations: the Sternoclavicular Joint, Acromioclavicular Joint, Scapulothoracic Joint, and Glenohumeral Joint.
โ Although the movements at each joint are continuous, they occur at varying rates throughout the elevation of the arm.
โ ๐ Scapular Rotations Relative to the Thorax
โ Upward or Downward Rotation: Occurs in the frontal plane around a dorso-ventral axis. Upward rotation turns the glenoid cavity cranially, while downward rotation turns it caudally.
โ Posterior or Anterior Tilting: Occurs in the sagittal plane around a latero-lateral axis.
โ External or Internal Rotation: Occurs around a cephalo-caudal (longitudinal) axis. External rotation brings the glenoid cavity closer to the frontal plane.
โ โฑ๏ธ ๐๐ก๐ ๐๐ข๐ฆ๐ข๐ง๐ ๐๐ง๐ ๐๐๐ญ๐ข๐จ
โ Scapulohumeral rhythm describes the timing of movement at the glenohumeral and scapulothoracic joints during shoulder elevation.
โ ๐ฏ Phases
โ Setting Phase (First 30 degrees):
โซ The initial 30 degrees of shoulder elevation is largely glenohumeral movement.
โซ Scapulothoracic movement during this phase is generally small and inconsistent.
โซ Motion primarily occurs at the GH joint, though stressing the arm may increase the scapular contribution.
โ Simultaneous Movement (After 30 degrees):
โซ Following the setting phase, the glenohumeral and scapulothoracic joints move simultaneously.
โ ๐ The Ratio
โ The movement is often cited as the widely accepted 2:1 ratio of glenohumeral elevation to scapulothoracic upward rotation.
โ For a full range of elevation, this means approximately 60ยฐ of GH motion combined with 30ยฐ of ST motion.
โ It is crucial to recognize that this ratio is often described as nonlinear, meaning the contributions of the scapula and humerus vary substantially at different points in the range of motion and among individuals.
โ ๐ฏ ๐๐ก๐ ๐๐ฎ๐๐ฅ ๐๐ฎ๐ซ๐ฉ๐จ๐ฌ๐ ๐จ๐ ๐๐๐๐ฉ๐ฎ๐ฅ๐จ๐ก๐ฎ๐ฆ๐๐ซ๐๐ฅ ๐๐ก๐ฒ๐ญ๐ก๐ฆ
โ Preserves Length-Tension Relationships: Prevents the glenohumeral muscles from shortening excessively by incorporating the scapula's upward rotation. This allows these muscles to sustain their force production through a larger portion of the range of motion.
โ Prevents Impingement: Prevents subacromial impingement between the humerus and the acromion. Due to the size difference between the glenoid fossa and the humeral head, simultaneous movement of the humerus and scapula during elevation limits the relative movement between the two bones.
โ โ ๏ธ ๐๐ก๐๐ง ๐ญ๐ก๐ ๐๐ก๐ฒ๐ญ๐ก๐ฆ ๐ข๐ฌ ๐๐ข๐ฌ๐ซ๐ฎ๐ฉ๐ญ๐๐: ๐๐๐๐ฉ๐ฎ๐ฅ๐๐ซ ๐๐ฒ๐ฌ๐ค๐ข๐ง๐๐ฌ๐ข๐
โ A change in the normal position of the scapula relative to the humerus results in a dysfunction of the rhythm known as scapular dyskinesia.
โ This condition is common, reported to occur in 68% to 100% of patients dealing with shoulder injuries, including labral tears, glenohumeral instability, and rotator cuff abnormalities.
โ ๐งญ Causes
โ Bony: Includes thoracic kyphosis or clavicula fracture.
โ Joint: May include high-grade AC instability, AC arthrosis, or GH joint internal derangement.
โ Neurological: Includes long thoracic or spinal accessory nerve palsy or Cervical Radiculopathy.
โ Inflexibility: Stiffness of the pectoralis minor or biceps short head can lead to protraction and anterior tilt. Soft tissue posterior shoulder inflexibility can cause a GH internal rotation deficit (GIRD).
โ Muscular: Decreased activation and strength of the Serratus Anterior is common in patients with shoulder pain, contributing to a loss of upward rotation and posterior tilt. Altered scapular motionโwhether due to muscle imbalance or other causesโis believed to disrupt the stability and function of the glenohumeral joint, contributing to impingement and rotator cuff pathology.
โ ๐
Athletic Adaptations
โ Athletes who perform overhead motions often show some asymmetry in scapular upward rotation and the rhythm ratio between their dominant and non-dominant shoulders; this may be an adaptation to sports practice rather than an automatic pathological sign.
โ ๐ ๐๐ฌ๐ฌ๐๐ฌ๐ฌ๐ข๐ง๐ ๐ญ๐ก๐ ๐๐ก๐ฒ๐ญ๐ก๐ฆ
โ Scapulohumeral rhythm is a frequent metric for evaluating muscle function and shoulder joint motion. Historically, Inman, Saunders, and Abbott first measured the rhythm using radiography.
โ Today, clinicians use imaging, goniometry, and advanced 3-dimensional tracking systems.
โ ๐๏ธ Clinical Assessment Methods
โ Palpation: The rhythm can be observed by palpating the scapula's positionโspecifically the inferior angle and the base of the spineโas the shoulder elevates.
โ Lateral Scapular Slide Test (LSST):
โซ Evaluates scapular symmetry under varying loads.
โซ Measurements are taken from the inferior angle of the scapula to the closest spinous process in three arm positions (relaxed at side, hand on iliac crest, and 90ยฐ abducted/internally rotated).
โซ An asymmetry of 1.5 cm in any position is the threshold for an abnormal pattern.
โ Scapular Dyskinesis Test (SDT):
โซ A visual test where the patient performs weighted shoulder flexion and abduction movements.
โซ Dyskinesis is characterized as winging or dysrhythmia.
โ ๐๏ธ ๐ ๐ฎ๐ป๐ฎ๐ด๐ฒ๐บ๐ฒ๐ป๐ ๐ฎ๐ป๐ฑ ๐ฅ๐ฒ๐ต๐ฎ๐ฏ๐ถ๐น๐ถ๐๐ฎ๐๐ถ๐ผ๐ป
โ Optimal rehabilitation requires identifying and addressing all causative factors that create the dyskinesis, and restoring the balance of muscle forces that control scapular motion.
โ Physical therapy management begins with a specific diagnosis of the cause of dysfunction. Treatment often addresses muscle shortening (such as the m. Pectoralis Minor or m. Levator Scapulae) and coordination deficits between essential muscles like the m. Serratus Anterior and m. Trapezius.
โ ๐ฏ Coordination Training
โ Setting Phase:
โซ The patient learns subtle muscle contraction, often requiring tactile or myofeedback.
โซ Consistent home practice is necessary to train the duration of muscle contraction across various postures of daily life.
โ Automation Phase:
โซ Contraction is automated through stabilization exercises.
โซ Exercises should be static and dynamic, and should avoid exercising on the back so that muscles are forced to stabilize the scapula rather than the ground.
โซ Examples include the push up plus, low-rowing, and dynamic hug.
โ It is essential that muscles are trained in functional patterns rather than isolated movements to maximize scapular muscle activations.
โ Because most abnormalities occur during fatigue or in the eccentric phase of movement, training should focus on muscle endurance and the eccentric phase.
โ Clinicians must also consider the influence of the spine, as conditions like Thoracic Hyperkyphosis may require passive or active mobilizations of the thoracic spine.
โ โจ ๐จ๐๐๐๐๐๐
โ Understanding the scapulohumeral rhythm is like appreciating the work of a highly synchronized rowing team. You have multiple joint "rowers" (GH, ST, AC, SC) working together. If one rower (say, the scapula) starts lagging or moving too soon, the smooth movement of the entire boat (the arm) is disrupted, leading to inefficiency and potential strain (impingement).
