Scapula Dyskinesis is an umbrella term for conditions that alter Scapula kinematics and has been described as a non-specific response to Pain experienced in The Shoulder Girdle region (SOURCE-1). While several attempts have been made to distinguish distinct types of Scapular Dyskinesis, it is generally present as one or a combination of Scapular Winging and Scapular Tilting .
The underlying cause(s) of Scapular Dyskinesis can typically be classified as one or a combination of altered tone and/ or recruitment of the following structures:
Serratus Anterior - one or more of its portions have displayed reduced or altered signalling (SOURCE-3). Paralysis of this muscle is the most common source of Scapular Winging and often attributed to Long Thoracic Nerve palsy (SOURCE-17)
Trapezius - imbalance between Upper and Lower fibres of the Trapezius . A relative insufficiency of the Upper fibes may lead to a reduction of Scapulothoracic Joint - Elevation which may (i) predispose impingement during arm elevation and (ii) fail to adequately maintain a slight upwards facing Glenoid Fossa (SOURCE-14+15+29). Conversely, a relative overactivity of the Upper Trapezius causes a superior migration of the axis of rotation for the Glenohumeral Joint which may also predispose impingement (SOURCE-30)
Pectoralis Minor - adaptive shortening of this muscle is generally regarded a potential mechanism of altered Scapular kinematics (SOURCE-12) and has been shown to restrict Posterior Scapular Tilting and External Rotation (SOURCE-11). One study finding the extent of the shortening was proportional to the presence of Dyskinesis (SOURCE-13)
Short Head of Biceps - akin to the Pectoralis Minor , shortening of this muscle can lead to increased Anterior Scapular Tilting and Scapulothoracic Joint - Protraction (SOURCE-19)
Levator Scapulae - as a Scapulothoracic Joint - Elevation and Scapulothoracic Joint - Downward Rotation Muscle , insufficiency may lead to excessive Scapulothoracic Joint - Upward Rotation during arm elevation as the muscle fails to counter the Upwards Rotation bias of the Trapezius (SOURCE-14)
GH Joint - External Rotation muscles
Posterior Glenohumeral Joint Capsule - restriction has been associated with a forward Scapula posture (SOURCE-19). Conversely, laxity may lead to excessive Scapulothoracic Joint - Downward Rotation and is commonly seen in overhead throwing sports (SOURCE-2)
Spiral Line - the Serratus Anterior forms a major link in this Fascia l continuity
Nerve - Through innervation of the aforementioned musculature, a Nerve Root Radiculopathy or Peripheral Nerve Neuropathy have the capacity to cause Scapular Dyskinesis:
Long Thoracic Nerve - LTN nerve palsy inhibits the Serratus Anterior , leaving the Trapezius unopposed. The causes the Scapula to migrate superomedially (aka Medial Scapular Winging ) (SOURCE-14+19)
Cranial Nerve XI - Accessory nerve palsy inhibits action of the Trapezius , leading to an inferolateral translation of the Scapula (aka Lateral Scapular Winging ) (SOURCE-14+19)
Dorsal Scapular Nerve - isolated injury to this nerve is rare but may present in a similar fashion to palsy of the Trapezius (Lateral Scapular Winging ) by disturbance of the Rhomboids . These rare instances are often attributed to entrapment by the Scalenes or direct trauma (SOURCE-19)
Suprascapular Nerve - Lidocaine induced nerve blocks resulted in significant increases in Scapulothoracic Joint - Upward Rotation and External Rotation during Scapula movement (SOURCE-5)
Cervical Spine Radiculopathy - Nerve Roots that arise from the Cervical innervate Scapula musculature directly and indirectly through Peripheral Nerve s. Scapular asymmetry appears more prevalent in those with Cervical Disc Herniation (SOURCE-23)
Additionally, exacerbated curvature(s) of the Vertebral Column have been shown to affect Scapula posture, leading to a cascade of reduced local muscle capacity and consequently disturbed Shoulder - Active Range of Motion (SOURCE-3):
Excessive Cervical Spine Lordosis
Excessive Thoracic Spine Kyphosis
Scoliosis - may lead to a Rib hump and altered resting position of the Scapula . On the convex side decreased Scapulothoracic Joint - Upward Rotation is expected along with Posterior Scapular Tilting and Internal Rotation (SOURCE-19). Conversely, the concave side usually has greater Anterior Scapular Tilting (SOURCE-19)
Chronic Scapular Dyskinesis has the capacity to disturb mechanics of The Shoulder Girdle and Vertebral Column via diverging mechanisms (SOURCE-3):
Narrowing of the Subacromial Space - which may cause or perpetuate symptoms of Secondary Subacromial Impingement
Threatening the fulcrum of the Head of the Humerus in the Glenoid Fossa - which may cause or further perpetuate Glenohumeral Instability
Increased Compressive/ Sheer forces at the Cervical Spine
Disturbed functional kinetic chain - forcing other structures to compensate
Overhead Throwing Athletes - an almost two-fold greater prevalence of Scapular Dyskinesis was reported in overhead throwing athletes when compared to other athletes (SOURCE-24)
Repetitive Overhead Work
While determining the prevalence of Scapular Dyskinesis is difficult as studies lack a standardisation of diagnostic criteria, it appears to have a high prevalence in both symptomatic and asymptomatic individuals. In the general population, Scapular Dyskinesis is present in ~60% of symptomatic individuals and a notable ~48% of asymptomatic individuals (SOURCE-25). Athletic individuals or those who have shoulder demanding jobs such as musicians have a higher symptomatic prevelence at ~81% (SOURCE-25). Converesely for individuals of this same subgroup who were asymptomatic, there was a wide ranging prevalence from 20-92% (~42% average) which suggests Scapular Dyskinesis may be a non-pathological adaptation to certain sports, in particular those that regularly engaged in overhead activity (SOURCE-25).
Scapular Dyskinesis has been described as a non-specific response to Pain in The Shoulder Girdle , with dyskinesis often occurring concomitantly with other shoulder pathologies (SOURCE-1+24). Protective compensatory mechanisms that may be beneficial in the short term can fester into pathomechanics that perpetuate symptoms (SOURCE-3). While specific patterns of dysfunction such as Scapular Winging and Scapular Tilting are standalone conditions; Dyskinesis can be derived from other conditions, play a causative role or occur concomitantly:
Subacromial Impingement - individuals displaying Scapula Dyskinesis have been shown to have a reduced Subacromial space (SORUCE-1). For impingement and Rotator Cuff pathologies alike, there is a strong association with altered Scapula kinematics. However, the precise abnormal motion varies and is likely to be contingent on the implicated soft tissue or severity. Decreased Scapulothoracic Joint - Upward Rotation and Posterior Scapular Tilting during shoulder elevation appear to be the most consistent findings; while increased Internal Rotation was also reported (SOURCE-4)
Rotator Cuff Pathology - Either a predisposing factor or sequela of a Rotator Cuff Tear or Tendinopathy is altered positioning and Motor Control of the Scapula (SOURCE-1). Scapular instability has been identified in as many as 68% of Rotator Cuff pathologies which may provide direction for treatment (SOURCE-2). Excessive Scapulothoracic Joint - Upward Rotation during arm elevation is a common presentation and is thought to be a compensatory mechanism for insufficient Rotator Cuff action (SOURCE-4). Like Impingement, the exact pathomechanic pattern is likely contingent on the specific tissue, severity, etc.
Glenoid Labrum Tear - abnormal positioning of the Scapula affects Glenohumeral Joint alignment which has the capacity to increase stress on the Glenoid Labrum (SOURCE-19)
Biceps Brachii - in response to altered Scapulohumeral Rhythm , activation of the Biceps generally increases as a compensatory mechnism to regain stability (SOURCE-27). With increasing chronicity, Scapular Dyskinesis and associated Glenohumeral Instability leave the already vulnerable Long Head of Biceps Tendon subject to further injury and may perpetuate a narrowing of the subacromial space (SOURCE-27). Scapular Dyskinesis during overhead throwing movements increases the posterior “peel-back” of the Long Head of Biceps on the Glenoid Labrum (SOURCE-27)
Adhesive Capsulitis - insufficient movement at the Glenohumeral Joint is compensated for with excessive Scapulothoracic Joint - Upward Rotation (SOURCE-6+19)
Cervical Spine Pathology - muscular connections through theAxio-Scapular muscles( Levator Scapulae and Trapezius ) and various Fascia l connections make interaction between the Scapula and Cervical spine plausible (SOURCE-7+ 8 +9+10)
Glenohumeral Instability - as displayed in Scapulohumeral Rhythm , the Scapulothoracic Joint and Glenohumeral Joint share the complex but coordinated task of appropriately positioning the Glenoid Fossa to maximise stability of The Shoulder Girdle in a highly mobile environment. Insufficiency from one joint appears to be compensated for by the other, however this appears to come at the expense of movement quality and may compromise associated soft-tissues. Glenohumeral Instability often results in reduced Scapulothoracic Joint - Upward Rotation and a corresponding increase in Scapulothoracic Joint - Protraction , particularly if instability is multidirectional (SOURCE-19).
Clavicle Fracture - structural shortening from mal or non-union requires additional Anterior Scapular Tilting and Internal Rotation to maintain adequate Scapula mechanics (SOURCE-19).
Acromioclavicular Joint Pathology - severe injury may lead to inferomedial displacement of the Scapula relative to the Clavicle due to disturbed clavicular mechanics. Consequent disruption to the Scapula ’s axis of rotation may lead to excessive Internal Rotation and Scapulothoracic Joint - Protraction (SOURCE-19).
This details dynamic observation of the Scapula during various pathokinematic patterns, for observation at rest see Scapula , for the observation of optimal patterns see Scapulothoracic Joint and Scapulohumeral Rhythm . While several attempts have been made to classify and quantify the extent of Dyskinesis (SOURCE-1), the observations remain relatively consistent:
Scapular Winging - identifiable as prominence of the Medial Border of the Scapula and a potentially greater lateral distance from the Thoracic Spine
Scapular Tilting - identifiable as either excessive elevation of the Superior Border of the Scapula or prominence of the Inferior Angle of Scapula
Dysrhythmia - presents as one or a combination of the following:
Excessive Scapulothoracic Joint - Elevation or Scapulothoracic Joint - Protraction when raising arm
Premature Scapulothoracic Joint - Downward Rotation when lowering arm
Loss of smooth/ fluid motion throughout movement
While comparison should be made to the asymptomatic side, it is important to note asymmetry is common (SOURCE-1). Other observable findings include abnormal curvature of the Vertebral Column such as Thoracic Spine Kyphosis or Cervical Spine Lordosis (SOURCE-19).
Shoulder - Active Range of Motion - most Pain ful motions should be performed last (SOURCE-15):
Weighted GH Joint - Flexion - a light (~3kg) dumbbell can be added to assess for dyskinesis. Typically the symptomatic side will have significantly less motion at the Scapulothoracic Joint around 35-45º of the Glenohumeral Joint (SOURCE-1).
GH Joint - Internal Rotation - a correlation between insufficient internal rotation and anterior tilting of the Scapula has been made (SOURCE-2).
Scapulothoracic Joint - Upward Rotation - excess may indicate Adhesive Capsulitis while a reduction indicates Subacromial Impingement
Muscle length testing for the following muscles is likely indicated:
Manual Muscle Testing of the following muscles may be indicated:
Trapezius - particularly Middle and Lower Fibres
The following Shoulder - Special Tests may be relevant in the diagnosis of Dyskinesis:
Lateral Scapular Slide Test - sensitivity 0.28-0.50, specificity 0.35-0.58
Scapular Retraction Test - sensitivity 1.00, specificity 0.33
Shoulder Flexion Resistance Test - evaluates muscular contribution to abnormal movement
Similarly, other Shoulder - Special Tests can be used to evaluate contribution from the Rotator Cuff .
In this context palpation can be used to determine relative muscular or Fascia l tone, signs of Inflammation or Pain / tenderness. The following Muscles may assist in assessment of Scapular Dyskinesis:
Posterior Glenohumeral Joint Capsule
Middle Scalene - for suspected nerve entrapment
Pectoralis Minor and Short Head of Biceps - for Coracoid-based inflexibility (SOURCE-27)
While treatment is contingent on the aetiology, the majority of Scapular Dyskinesis cases can expect sufficient recovery with conservative management alone. Significant amelioration of Pain and impaired function has been reported within 6 weeks; however, a full recovery may take months up to years (SOURCE-17+19+20). Conservative treatment guidelines can generally be split into three phases, distinguished by their treatment recommendations and desirable outcomes (SOURCE-21):
Initial Phase (0-3 weeks) - painful movements and positions should be avoided with the aim of reducing excessive Inflammation to relieve pain/ swelling. Mobilisation of soft-tissues through myofascial release or stretching may be indicated. When tolerated, early-phase strengthening exercises may be introduced to slow muscle atrophy and promote mobility. These exercises, for the most part, should be restricted to isometric Muscle Contraction s, closed-chain and low Range of Motion exercises
Recovery Phase (3-8 weeks) - while being mindful of extreme ranges or positions, this phase aims to restore painless range of motion and muscle strength. Starting with basic, closed-chain exercises, range of motion and load can be progressed
Maintenance Phase (6-10 weeks) - quality Scapulohumeral Rhythm should be present, which serves as a benchmark for the initiation of mid-to-late phase strengthening exercises. This may include plyometric exercises and should include exercises that emphasise a large range of motion overhead. The goal of this phase is to improve Proprioception and Muscle Performance through integrating functional patterns
Stretching of the Scapulothoracic Joint musculature has been shown to improve position of the Scapula (SOURCE-1). If not specified below, stretches can be found on their respective pages (SOURCE-3+28):
Posterior Glenohumeral Joint Capsule
Genie Stretch - rudimentary horizontal adduction stretch
Sleeper Stretch - greater emphasis on GH Joint - Internal Rotation
Sleeper Stretch MWM - internal rotation stretch combined with Humerus Mobilisation
Pectoralis Minor - has been shown to often be restricted in Dyskinesis (SOURCE-2), further stretching of this muscle has been shown to increase Posterior Scapular Tilting and External Rotation (SOURCE-11)
Door Frame Shoulder Stretch (Pectoralis Minor variant) - self-guided anterior shoulder stretch with large Horizontal GH Joint - Abduction range
Door Frame Neck Stretch (Levator Scapulae variant) - accessible neck stretch with large variably directed range
Split Stance Biceps Stretch - self-guided anterior shoulder stretch with large GH Joint - Extension range
Banded Capsule Rolls - split stance biceps variation that emphasises shoulder rotation
Seated Thoracic Rotation with Breathing - couples lateral flexion and rotation with breathing
Bent Over Lat Stretch - accessible active stretch with large GH Joint - Flexion or Horizontal GH Joint - Adduction range
Swimmers Oblique Extensions - exercise that may be used to lengthen entire Lateral Line through large body-wide lateral-flexion range
Other potentially relevant stretches:
Shoulder External Rotation Stretch - rudimentary active stretch with large GH Joint - External Rotation range and several variations
Dowel External Rotation Stretch - self-guided GH Joint - External Rotation stretch with overpressure
Shoulder Dislocates - mobility exercise that emphasises the greatest circumduction range possible
Bretzel 1.0 - whole body technical stretch that incorporates anterior shoulder
Bretzel 2.0 - variation with greater hip extension range
Wheel Pose - full bridge variation that lengthens entire anterior chain
In a similar fashion to streching, exercise therapy fails to display a consistent positive effect on Scapular Dyskinesis yet appears to aid with associated Pain and disability (SOURCE-22). This may at least in part be attributed the standardisation of exercise protocols used in controlled studies that fails to meet the subjective needs of each test subject, as dysfunction of the Rotator Cuff is highly related to pathologies of the Scapula (SOURCE-2). Further, some studies have found strength training of the Scapulothoracic Joint musculature to improve position of the Scapula (SOURCE-1). Of particular focus are the following motions; Scapulothoracic Joint - Retraction , Posterior Tilting and External Rotation (SOURCE-26). In the initial phase training volume should be monitored, as training Scapular stabilisers to the point of fatigue may perpetuate its malposture (SOURCE-2). Generally speaking the following muscle groups should be emphasised with consideration to their function and relations (SOURCE-21+3):
Shoulder Depressors - Subscapularis , Infraspinatus and Teres Minor
Scapular Stabilisers - Serratus Anterior , Rhomboids and Trapezius where its lower and middle fibres after often relatively weaker than its upper fibres
Primary Shoulder Movers - Pectoralis Major , Deltoid and Latissimus Dorsi
Initial-Phase- initiate activation of weak/ dysfunctional muscles through the use of Isometric and Isotonic Muscle Contraction s, operating within pain-free ranges (SOURCE-2+3+26):
Scapular Pinches - basic isometric exercise for Scapula Retractors
Cat-Cow - promotes Vertebral Column movement and mild activity of all Trapezius fibres
Push-Up Plus - wall variation - bilateral isotonic exercise for Scapular Protractors
Band Pull-Apart - basic isotonic exercise for Scapular Retractors
Thoracic Extension Exercises - rudimentary exercise progression
Y-Raise - light isotonic exercise that emphasises Trapezius, particularly mid/low fibres
Quadruped Thoracic Rotation - bodyweight isotonic exercise for Scapular Retractors
Shrug - Upwards Rotation variant - relevant where Upwards Rotation is deficient
Scapular Punches - unilateral isotonic exercise for Scapular Protractors
Dynamic Hug - isotonic exercise for Scapular Protractors
Circumduction Row - isotonic exercise for Scapular Retractors
Bird-Dog - bodyweight exercise that emphasises full arm elevation and the Posterior Sling
Mid-Phase- once little-to-no Pain is present when the arm is elevated, the patient may begin to increase Range of Motion and progress to strengthening of the Scapulothoracic Joint musculature (SOURCE-2+3+26):
Scapular Pinches - Swiss Robbery Pinches w/ DB’s variation - isometric, moderate load Scapular retraction exercise
Push-Up / Push-Up Plus - isotonic bodyweight exercise that integrates basic functional patterns while emphasising scapular protractors
Seated Row - or High Row variation - moderate-to-high load isotonic Scapula retraction exercise
Lat Pulldown - isotonic exercise that promotes downwards rotators of Scapula
Reverse Woodchopper - isotonic exercise that emphasises Serratus Anterior and Mid/Low Trapezius through a movement that promotes Scapulohumeral Rhythm
Manually Resisted Scapular Motions - resistance applied by practitioner to emphasise desired motion
Bottoms-Up Kettlebell Walk - emphasises Scapular Stabilisers
Overhead Press - isotonic strength exercise that approaches maximum range overhead
DB Shoulder Press - overhead press variation that loads each side independently
Late-Phase- with adequate strength and range attained, patients should be progressed to exercises that more closely reflect activities of daily living or sport. As recovery progresses so too will range of motion, intensity and speed; while exercise selection extends beyond the environment local to the Scapula to incorporate functional patterns or address other predisposing malpostures such as Thoracic Spine Kyphosis or Forward Head Posture (SOURCE-2+3+26):
Shoulder Rotation Ball Plyometrics - low load and range, repetitive movements that emphasise shoulder rotation in various functional positions that involve overhead throwing
Bear Crawl on Swiss Ball - legs on ball, hands crawl in/ out while maintaining neutral spine
Seated Pike Lift - isometric holds emphasising Scapular stabilisers
Prone Lat Pulldown - variation that emphasises scapular stractors and thoracic extension
Push Press - explosive overhead press progression that incorporates the lowerbody
Kneeling Landmine Press - explosive isotonic exercise through large overhead range
Half DB Bench Press - unilateral pressing motion that emphasises Anterior Sling and Posterior Sling
Bird-Dog Row - unilateral unstable exercise that emphasises scapular retraction and the Posterior Sling
Split Stance Landmine Press - unilateral, body-wide, explosive isotonic exercise through large overhead range
Medball Pullover Throw - explosive low load, large shoulder and thoracic range exercise
Lu Raises - low load full abduction range, emphasising scapular upwards rotators
Given the multifaceted and often concomitant origins of Scapular Dyskinesis, Mobilisations of the Scapula, Glenohumeral Joint , Cervical Spine and Thoracic Spine may be relevant. Often a primary focus is the restoration of Scapulothoracic Joint - Retraction , Posterior Tilt and External Rotation of the Scapula (SOURCE-18+26): Joint Play
Scapulothoracic Joint - direct treatment
Cervical Spine - in addition to a PACVP , PAUVP or TVP applied to a desired Cervical segment, the following techniques may be of relevance for a suspected Radiculopathy :
Posterior Glide on Humerus - particularly relevant when posterior capsule tightness is present
Shoulder - MWM 1 - applied to the Clavicle and Scapula
Shoulder - MWM 2 - applied to the medial Clavicle and Scapula
Shoulder - MWM 3 - applied to the Scapula and Humerus
Shoulder - MWM 4 - applied to the Scapula and Humerus
Shoulder - MWM 5 - applied to the Scapula and Humerus
Cervical Spine - in addition to NAGS or SNAGS applied to a relevant Cervical segment, the following techniques may be indicated with suspected Radiculopathy :
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Upper and Lower Trapezius
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