scapular dyskinesia: shoulder’s nightmare-a narrative review on...

Miraj Medical Center Journal of Physiotherapy 2019 VOL 1 NO. 1 3 www.mmcjopt.org

Scapular dyskinesia: Shoulder’s Nightmare-A Narrative

Review on Current concepts

Dr Ajit S Dabholkar (M.P.Th, PhD)1

1Professor and Head of Sports Physiotherapy, School of Physiotherapy,

D.Y.Patil University, Nerul, Navi Mumbai

Address all correspondence and requests for

permission: Dr Ajit S Dabholkar

Email- [email protected]

Phone- +919892502160

Copyright: 2019 Miraj Medical Centre’s Journal of Physiotherapy

Abstract:

Background: The ‘‘Scapula Summit’’

was founded, where experts in this field

meet to discuss the biomechanical and

clinical factors attributed to the scapula

in causing shoulder pathologies, in

particular, ‘‘scapula dyskinesis. In this

review the author explored the

contemporary concepts in the

understanding and management of

scapular dyskinesis.

Objectives: To appraise the literature

and understand the current concepts in

evaluation of scapular dyskinesis,

clinical implications and factors

influencing abnormal kinematic

alterations and relevant strategies for

management.

Methods: Literature review of

scapular dyskinesis and its implications

were selected by an approach called

“best evidence synthesis.” The articles

included were searched in Databases

like PubMed, Cochrane and Google

scholar. Articles included were current

approaches in assessment and

management of scapular dyskinesis,

Systematic Reviews, Metaanalysis,

Current Literature review.

Discussion: There is evidence of

scapular kinematic alterations

associated with shoulder impingement,

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rotator cuff tendinopathy, rotator cuff

tears, glenohumeral instability,

adhesive capsulitis, and stiff shoulders.

There is also evidence for altered

muscle activation in these patients,

particularly, reduced serratus anterior

and increased upper trapezius

activation. Scapular kinematic

alterations similar to those found in

patient with a short rest length of the

pectoralis minor, tight soft-tissue

structures in the posterior shoulder

region, excessive thoracic kyphosis.

This suggests that attention to these

factors is imperative in the clinical

evaluation of scapular dyskinesis and

appropriate strategy need to be

intervened.

Conclusion: The published clinical

evidence endorses clinical evaluation

of scapular dyskinesia and its

associated impairments. The is a need

to understand the factors influencing

scapular dyskinesia through a thorough

comprehensive movement system

impairment. This will ensure

appropriate physiotherapy intervention

with sound clinical reasoning. This will

impact patient outcome positively and

improve quality of life in long term.

Key words: Scapula, Scapular

dyskinesia, Scapular rehabilitation,

scapular kinematics, scapular

dysfunction

Introduction:

The exact role and the function of the

scapula are misunderstood in many

clinical situations. This lack of

awareness often translates into

incomplete evaluation and diagnosis of

shoulder problems. In addition,

scapular rehabilitation is often ignored.

Recent research, however, has

demonstrated a pivotal role for the

scapula in shoulder function, shoulder

injury, and shoulder rehabilitation.1

Understanding of the shoulder and

surrounding structures has increased it

has become well accepted that the

scapula plays several roles in

facilitating optimal shoulder complex

function when scapulohumeral

anatomy and biomechanics interact to

produce efficient movement.2

In normal upper quarter function, the

scapula provides a stable base from

which glenohumeral mobility

occurs.2 Stability of the scapulothoracic

joint depends on coordinated activity of



the surrounding musculature. The

scapular muscles must dynamically

position the glenoid so that efficient

glenohumeral movement can occur.

When weakness or dysfunction of the

scapular musculature is present,

normal scapular positioning and

mechanics may become

altered.2 When the scapula fails to

perform its stabilization role, shoulder

complex function is inefficient, which

can result not only in decreased

neuromuscular performance but also

may predispose the individual to injury

of the glenohumeral joint.

Methods: The articles included were

searched in Databases like PubMed,

Cochrane and Google scholar. Articles

included were current approaches in

assessment and management of

scapular dyskinesis, Systematic

Reviews, Meta-analysis, Consensus

guidelines, Current Literature review. In

addition, the articles were also

manually checked for relevant articles

in peer reviewed journals. The search

terms were scapula, scapula

dyskinesis, scapular dysfunction,

scapular rehabilitation, and scapular

kinematic alteration.

Normal Scapula Biomechanics: The

scapula fulfils many roles to facilitate

optimal function of the shoulder. Its full

mobility is unlikely to be initially

appreciated due to its coverings of

muscles. The scapula’s only bony

articulation is with the clavicle at the AC

joint which acts as a bony strut for the

shoulder. There is no articulation with

the posterior thoracic wall. This lack of

congruency allows the scapula to be

mobile, allowing movements of

elevation, depression (superior

translation [ST]/inferior translation),

retraction, protraction (PRO), internal

rotation (IR)/external rotation,

anterior/posterior tilt, and upward

rotation (UR)/downward rotation. These

movements occur via a gliding motion

of the scapula on the thoracic cage

secondary to contraction of serratus

anterior and subscapularis.3

There are a number of muscles that

surround and insert to the scapula,

which can be divided functionally into

three groups.1 First, muscles that

contributes to scapula stability and

rotation-trapezius, rhomboids, levator

scapulae, and serratus anterior.

Second, the extrinsic muscles of the

glenohumeral joint, deltoid, biceps, and

triceps; and a third group of intrinsic

muscles, or the ‘‘shoulder protectors’’

comprising the rotator cuff muscles,



supraspinatus, infraspinatus, teres

minor, and subscapularis.

Mechanically, the coordinated coupled

motion between the scapula and

humerus, often termed scapulohumeral

rhythm, is needed for efficient arm

movement and allows for glenohumeral

alignment in order to maximize joint

stability.4

McClure et al.5 found that during

scapular plane elevation of the arm in

normal subjects, there was a consistent

pattern of scapular upward rotation,

posterior tilting, and external rotation

along with clavicular elevation and

retraction.5 Scapular upward rotation is

the predominant scapulothoracic

motion. The motion of the scapula with

regard to changes in scapular internal

rotation angles shows more variability

across subjects, investigations, planes

of elevation, and point in the range of

motion of elevation.5-7 It has generally

been found that end range elevation

involves some scapulothoracic external

rotation, however, some studies report

internal rotation during elevation and

limited data are available.5

Pathomechanics: The scapular roles

can be altered by many anatomic

factors to create abnormal

biomechanics and physiology, both

locally and in the kinetic chain.

Most of the abnormal biomechanics

and overuse injuries that occur about

the shoulder girdle can be traced to

alterations in the function of the

scapular stabilizing muscles.8, 9

Altered scapular motion and position

have been termed scapular dyskinesis.

The definition of dyskinesis is the

alteration of normal scapular

kinematics.4 Many factors may

contribute to the development of

scapular dyskinesis including but not

limited to bony causes, including

posture (increased thoracic kyphosis)

or previous fracture (clavicle). Joint

causes including acromioclavicular joint

instability, acromioclavicular joint

arthrosis, and glenohumeral joint

internal derangement. Neurological

causes including cervical radiculopathy

or nerve palsy (long thoracic nerve or

spinal accessory nerve). Soft tissue

factors including inflexibity (tightness of

pectoralis minor) or intrinsic muscle

problems, and alterations in

periscapular muscle activation.

Discussion:

Scapular dyskinesis:



Scapular dyskinesis is defined as

observable alterations in the position of

the scapula and the patterns of

scapular motion in relation to the

thoracic cage.10

‘Dys’ (alteration of ) ‘kinesis’ (motion) is

a general term that reflects the loss of

normal control of scapular motion.

Dyskinesis by itself is not a diagnosis.

Muscle inhibition or weakness is quite

common in glenohumeral pathology,

whether from instability, labral

pathology, or arthrosis.10-13

The serratus anterior and the lower

trapezius muscles are the most

susceptible to the effect of the

inhibition, and they are more frequently

involved in early phases of shoulder

pathology.14Muscle inhibition and

resulting scapular dyskinesis appear to

be a nonspecific response to a painful

condition in the shoulder rather than a

specific response to a certain

glenohumeral pathology.

This fact is supported by the finding of

scapular dyskinesis in as many as 68%

of patients with rotator cuff

abnormalities, 94% with labral tears,

and 100% with glenohumeral instability

problems.15, 16

Inhibition is seen as a decreased ability

of the muscles to exert torque and

stabilize the scapula as well as

disorganization of the normal muscle

firing patterns of the muscles around

the shoulder.12, 14 The exact nature of

this inhibition is not clear

Clinical assessment of Scapular

Dyskinesis: The goal of scapular

assessment is to identify abnormal

scapular motion or positioning,

determine any relationship between

altered motion and symptoms, and

identify underlying causative factors of

movement dysfunction.17-19

Clinical assessment of scapular

dyskinesis is inherently challenging due

to the 3-dimensional nature of scapular

movement and soft tissue surrounding

the scapula obscuring direct

measurement of bony positioning.

Clinical evaluation of scapular

dysfunction should include 3 basic

elements: (1) visual observation to

determine the presence or absence of

scapular dyskinesis in the symptomatic

patient; (2) the effect of manual

correction of dysfunction on symptoms;

and (3) evaluation of surrounding

anatomic structures that may be

responsible for dyskinesis



The Lateral Scapular Slide Test is a

static measurement of the side-to-side

difference of the distance from the

inferior angle of the scapula to the

adjacent spinous process.20

The measures are performed with the

arms in 3 different positions and a side-

to-side difference of >1.5 cm should be

considered pathological. This test has

demonstrated fair to moderate levels of

reliability and is easily applied in a

clinical setting.21, 22

The major advantage of the lateral

scapular slide test is its ease of use in

the clinic. However, the validity of this

test has been questioned because of

the findings that both symptomatic and

asymptomatic individuals will

demonstrate asymmetry when

measured in this manner.22, 23

The static, and 2-dimensional nature of

this test fails to assess the dynamic 3-

dimensional scapular motion, Thus with

questionable validity of results requires

the use of other methods of scapular

assessment during clinical examination

Classification of Scapular

Dyskinesis:

Patterns of abnormal motion in scapular

dyskinesis are best observed by first

determining the position of the scapula

with the patient’s arms at rest at the

side, then by observing the scapular

motion as the arms are elevated and

lowered in the scapular plane.

These dyskinetic patterns fall into three

categories, which correspond to the

three planes of motion on the ellipsoid

thorax.24 This system can help identify

the type of abnormal scapular motion

and thus the rehabilitation required by

muscle strengthening and restoration of

flexibility. Type I is characterized by

prominence of the inferior medial

scapular border. This motion is

primarily abnormal rotation around a

transverse axis. Type II is characterized

by prominence of the entire medial

scapular border and represents

abnormal rotation around a vertical

axis. Type III is characterized by

superior translation of the entire

scapula and prominence of the superior

medial scapular border. The net effect

of the scapular dyskinetic patterns is an

adverse effect on the normal role of the

scapula in shoulder function.20

Scapula dyskinesis test (SDT):

The patient is asked to flex and abduct

their shoulder while carrying light

weights.25 He or she performed 3

repetitions of bilateral weighted flexion

and weighted abduction. The tests



were performed with participants

grasping dumbbells, using 1.4 kg (3 lb)

for those weighing less than 68.1 kg

(150 lb) and 2.3 kg (5 lb) for those

weighing 68.1 kg or more.

The therapist then observes to see if

there is any protrusion of the

medial/inferior borders of the scapula

away from the thorax sometimes

referred to as winging; however, it is not

a true winged scapula as seen in long

thoracic nerve palsy. Visual

assessment offers an alternative to

linear measures for evaluating 3-D

scapular motion in a practical clinical

method that incorporates dynamic

upper extremity tasks that require both

raising (concentric) and lowering

(eccentric) phases

Uncoordinated movements, such as

early/late scapula elevation and

stuttering, also are noted. This test uses

the visually altered 3D kinematics of the

scapula in dyskinetic shoulders. A

second group of authors 26 modified the

same test, by assessing defined

parameters, recording any positive

findings as a yes, and normal findings

as a no. This is currently the gold

standard for observational testing.4, 17

Rating Scale

Each test movement (flexion and

abduction) rated as

a) Normal motion: no evidence of

abnormality

b) Subtle abnormality: mild or

questionable evidence of abnormality,

not consistently present

c) Obvious abnormality: striking, clearly

apparent abnormality, evident on at

least 3/5 trials (dysrhythmias or winging

of 1 in [2.54 cm] or greater

Displacement of scapula from thorax)

Final rating is based on combined

flexion and abduction test

movements.

Normal: Both test motions are rated as

normal or 1 motion is rated as normal

and the other as having subtle

abnormality.

Subtle abnormality: Both flexion and

abduction are rated as having subtle

abnormalities.

Obvious abnormality: Either flexion or

abduction is rated as having obvious

abnormality.

The corrective maneuvres of

scapula: Several examination methods

are intended to passively alter the

position of the scapula to assess



change in shoulder muscle strength,

pain, or both, compared to the natural

unassisted condition during arm

elevation. Both the scapular retraction27

and reposition tests28 have been shown

to influence muscle strength, but the

influence of these on scapular position

has not been studied

Scapula assistance test (SAT): The

SAT was initially performed with the

examiner manually assisting the

scapula into upward rotation by pushing

the inferior medial border of the scapula

as the patient elevated the arm, 20 and

has since been described to include

manual assistance into both upward

rotation and posterior tilt.29 In theory,

the SAT alters the position of the

scapula, increases subacromial space,

and may influence rotator cuff muscle

strength in individuals with SAIS.

Scapular repositioning test (SRT): In

SRT the examiner emphasized

posterior tilting and external rotation of

the scapula but avoiding full retraction

and named it the Scapula Reposition

Test. With the application of a manual

repositioning maneuver, the patients’

symptoms were reduced. Manual

repositioning of the scapula

significantly increased strength in a

subgroup of athletes, regardless of the

absence or presence of impingement

symptoms. The SRT is a simple clinical

test that may potentially be useful in an

impairment based classification

approach to shoulder problems. The

scapula reposition test may be a way to

identify athletes most suitable for

interventions addressing the scapula,

such as strengthening, taping, or

bracing.

Treatment of Scapular Dyskinesis:

Most of the abnormalities in scapular

motion or position can be treated by

physical therapy to relieve the

symptoms associated with inflexibility

or trigger points and to re-establish

muscle strength and activation

patterns.20, 30

During the physical examination, the

therapist should address all possible

deficiencies found on different levels of

the kinetic chain. Based on the results

of clinical assessment, appropriate

treatment goals should be set leading to

proper rehabilitation strategies.

There is some support for the use of

scapular-focused exercise therapy in

patients with SPS (Subacromial pain

syndrome). Owing to the low number of

studies, more randomised controlled

trials are needed to determine the



clinical outcomes of scapular-focused

exercise therapy.31

In another study, adults with SPS,

scapular focused interventions can

improve short-term shoulder pain and

function.32

An analysis by two recent systematic

reviews 31,33 indicated some support for

scapular-focused exercise approaches,

although the evidence was either

conflicting or below clinical significance

for variables such as pain, scapula

position/movement, range of motion,

and rotator cuff strength.

Another study emphasized conscious

correction of scapular orientation34.The

proposed strengthening and motor

control protocol was determined

through the selection of exercises

focused on the scapulothoracic joint

and periscapular muscles that are used

in clinical practice.35

There is no consensus with regard to

neuromuscular control exercises, and

for this reason, exercises that included

visual, auditory, or kinesthetic feedback

were used, with an emphasis on the

retraction of the scapula during their

execution.

In the selection of rehabilitation

exercises, the clinician should have a

preference for exercises with high

activation of the LT and MT and low

activity of the UT.36 The figure 1 gives

the scope of scapular rehabilitation in

management of shoulder pain.

Fig 1 Scapular Rehabilitation Algorithm (Cools et al36)

Summary of common Interventions:



Table No 1

Pathologic states Scapular

kinematic

alterations

Proposed Biomechanical Mechanisms of

Scapular Kinematic Deviations7

Impingement or

Rotator Cuff Disease

Lesser upward

rotation, Lesser

posterior tilting,

Greater internal

rotation

Associated

effects:

Lesser scapular

upward rotation

and posterior

tilt

Mechanism:

Inadequate

serratus

activation

Intervention

Serratus anterior

strengthening or

retraining37-39

Glenohumeral Joint

Instability

Lesser upward

rotation, Greater

internal rotation

Greater

clavicular

elevation

Excess upper

trapezius

activation

Upper trapezius

activation

reduction40

Adhesive Capsulitis Greater upward

rotation

Greater

scapular

internal

rotation and

anterior tilt

Pectoralis

minor tightness

Pectoralis minor

stretching41,42

Greater

scapular

anterior tilt

Posterior

glenohumeral

joint soft tissue

tightness

Posterior shoulder

stretching43,44

Greater

scapular

internal

rotation and

anterior tilt,

lesser scapular

upward

rotation

Thoracic

kyphosis or

flexed posture

Thoracic extension

posture and

exercise45



Rehabilitation for scapular dyskinesis

should start proximally and end distally.

It should include the whole kinetic chain

rehabilitation. The ultimate goal of

physical therapy is to achieve the

position of optimal scapular function.

The sequence of rehabilitation

exercises may need to be adapted for

individual cases based on the rate of

progress at each specific stage.

The biomechanical analysis of

rehabilitation exercises has gained

recent attention. Advances in the

understanding of the biomechanical

factors of rehabilitation have led to the

enhancement of rehabilitation

programs that seek to facilitate

recovery, while placing minimal strain

on specific healing structures. The

summary of intervention is given in

Table 1.

There is need to study the influence of

scapular dyskinesis in long term in

normal as well as various clinical

scenarios/patients. The impact of

integration of the whole-body kinetic-

chain approach to strengthening and

rehabilitating injuries needs

consideration. The impact of

multiplanar movement in addition and

strength, posture, balance (stable and

dynamic surface, and neuromuscular

control are all vital components to any

injury prevention of rehabilitation

program. Thus, integrated approach to

scapular rehabilitation can be used by

the therapist to design appropriate

rehabilitation and injury prevention

programs. Wilmore and Smith propose

a paradigm shift (Fig 2) whereby

scapular dyskinesia is seen not in

isolation but is considered within the

broader context of patient-centred care

and an entire neuromuscular system.

Fig 2: Scapular dyskinesis:

traditional model versus a

symptoms and systems-based

approach (Wilmore and Smith).

Conclusions: Scapular dyskinesis is

common entity in shoulder pain. Use of



valid measure to clinically assess

scapular dyskinesis is important.

However, the various associated

factors need to be studied to identify

movement system impairments. The

movement system is the core

competency of the physical therapist. It

is therefore important to identify the

prime glenohumeral and scapular

movement dysfunction with sound

clinical decision making process. This

will enhance patient management with

appropriate exercise programs for

injury rehabilitation and prevention.

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https://www.ncbi.nlm.nih.gov/pubmed/?term=Yoo%20Wg%5BAuthor%5D&cauthor=true&cauthor_uid=29581661

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5857448/

scapular dyskinesia: shoulder’s nightmare-a narrative review on...

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