The Scapulothoracic Joint is not a true joint per se but rather a point of contact between the anterior surface of the Scapula and the posterior-lateral wall of the Thorax . The Scapulothoracic Joint is one of 5 joints or articulations that comprise The Shoulder Girdle . While movement at the Scapulothoracic Joint is dependent on refinements at the Sternoclavicular Joint and Acromioclavicular Joint , it it closely related to movement at the Glenohumeral Joint and often forms movement couplings. The Scapula is typically positioned on the Thorax between the 2nd and 7th Ribs , with the Medial Border ~6m lateral of the Vertebral Column .
The movements that occur between the Scapula and the Thorax are a result of cooperation between the Acromioclavicular Joint and Sternoclavicular Joint , together forming theScapulothoracic Articulation. These joints serve to optimise positioning of the Glenohumeral Joint and afford it a stable foundation upon which to move. Given this function, movements available to the Scapulothoracic “joint” often occur in combination:
The coordinated motion between the Scapulothoracic Joint and the Glenohumeral Joint is known as Scapulohumeral Rhythm . In lieu of a true synovial articulation, gliding surfaces are formed by Fascia of the Subscapularis and Serratus Anterior (SOURCE-3)
The general term for pathomechanics of the Scapulothoracic Joint is Scapular Dyskinesis . This can present as Scapular Winging , Scapular Tilting at rest or during movement as indicated by Scapulohumeral Rhythm . Appropriate mechanics are contingent on the other joints of The Shoulder Girdle and dynamic stabilisers (muscles) which compensate for a lack of bony congruency at the Scapulothoracic Joint. For specific pathomechanics associated with each movement, see the individual movement pages found underKinematics.
There are several pathologies that are commonly related to the Scapulothoracic Joint, as predisposing or maintaining factors or a sequelae. For more specific accounts of how each pathology relates to each direction of movement, see the individual movement pages found underKinematics.
Scapular Dyskinesis - the umbrella term for altered Scapula kinematics, such as Scapular Winging or Scapular Tilting , that may predispose shoulder pathology or represent a compensatory response. During elevation of the arm, certain dyskinetic patterns may implicate particular tissues:
Scapular Winging - often attributed to weakness in the Serratus Anterior or Middle and Lower Trapezius , with the former typically presenting asMedial Wingingand the latterLateral Winging
Scapular Tilting - hypertonicity of the Pectoralis Minor often presents with increased Anterior Tilting and Scapulothoracic Joint - Downward Rotation which restrcits Scapulothoracic Joint - Upward Rotation motion (SOURCE-3)
Premature/ Excessive Scapulothoracic Joint - Upward Rotation - hypertonicity of the Upper Trapezius causes a superior migration of the Glenohumeral Joint ’s axis point (SOURCE-4)
As described below, disturbance to normal Scapulohumeral Rhythm such as a failure to adequately lift the Acromion or accurately place the Glenoid Cavity predisposes several shoulder pathologies including Subacromial Impingement , Glenohumeral Instability and Rotator Cuff pathology (SOURCE-1+4+5).
Subacromial Impingement - a major role of the Scapulothoracic Joint is to place the Glenoid Cavity in an optimal position for articulation with the Head of Humerus . During arm elevation this requires ensuring the cavity is facing upwards to maximise overhead range and facilitate adequate clearance of the Humeral Head from under the Acromion. Certain dyskinetic patterns commonly impose on this function. A decrease and increase in Scapulothoracic Joint - Upward Rotation may predispose impingement through diverging mechanisms. A decrease may limit the ability of the Acromion to elevate, causing the elevating Humerus to impinge on the undersurface of the Coracoacromial arch (SOURCE-13). An increase in Upwards Rotation may lead to a superior migration of the Glenohumeral Joint ’s axis of rotation which also predisposes impingement (SOURCE-4). In a similar fashion, Glenohumeral Joint restriction paired with a Scapulothoracic Joint - Protraction posture predisposes impingement during arm elevation (SOURCE-3+15).
Glenohumeral Instability - given the codependent relationship of Scapulohumeral Rhythm , it is perhaps unsurprising Scapula Instability has been identified in as high as 100% of Glenohumeral Joint instability instances (SOURCE-1). A reduction in Scapulothoracic Joint - Upward Rotation is generally regarded as a common response to instability, particularly if the instability is inferior or multidirectional (SOURCE-11+12). This may be a compensatory response to prioritise stability over mobility and ensure the Glenoid is appropraitely oriented (SOURCE-13). In instances of instability, a reduction in Upwards Rotation typically corresponds with an increase in Scapulothoracic Joint - Protraction (SOURCE-15). Conversely, a loss of normal Protraction may also predispose injury during particular movements such as overhead throwing as it alters the safe-zone, increasing the risk of Glenoid Labrum Tears (SOURCE-15).
Rotator Cuff pathologies - have presented with a component of Scapula Instability in as high as 68% of instances (SOURCE-1). Greater Scapulothoracic Joint - Downward Rotation (or decreased Scapulothoracic Joint - Upward Rotation ) is often displayed during arm elevation with Rotator Cuff insufficiency (SOURCE-3). Restriction in the Posterior Glenohumeral Joint Capsule often results in a combined posture of excessive Scapulothoracic Joint - Protraction and Scapulothoracic Joint - Depression which predisposes Rotator Cuff pathology (SOURCE-3).
Nerve Palsy - Entrapment or compromise of the following nerves may alter motion at the Scapulothoracic Joint
Cranial Nerve XI Palsy - a common cause of Upper Trapezius insufficiency which reduces its antagonistic resistance to Downwards Rotation. May result from blunt trauma, such as those described in more severe forms of Acromioclavicular Joint Dislocation , or more commonly represent a complication of surgical procedures that involve thePosterior Cervical Triangle(SOURCE-9+10)
Long Thoracic Nerve - inhibition of the Serratus Anterior leaves the Trapezius unopposed, causing excessive Scapulothoracic Joint - Elevation and Scapulothoracic Joint - Retraction (SOURCE-16). The Long Thoracic Nerve may be compromised from trauma or repetitive strain, particularly in Scapulothoracic Joint - Depression where the neck and shoulder are rotated or from surgical complications (SOURCE-16+17)
Dorsal Scapular Nerve - compromise may lead to inhibition of the key downwards rotators ( Levator Scapulae and Rhomboids ). Pararlysis is most often attributed to entrapment of the Dorsal Scapular Nerve at the Middle Scalene (SOURCE-6)
Medial Pectoral Nerve - while injury is rare, it may result from trauma (usually direct blow or excessive stretch) or entrapment caused by a hypertonic or hypertrophic Pectoralis Minor (SOURCE-8+7). This may lead to weakness, chronic Pain and atrophy of the Pectoralis Major and/or Pectoralis Minor (SOURCE-7)
Vertebral Column Posture - both excessive Cervical Spine Lordosis and Thoracic Spine Kyphosis have been described to correspond with an increase in Scapulothoracic Joint - Protraction or Scapulothoracic Joint - Downward Rotation to predispose pathologies such as Subacromial Impingement or Scapular Dyskinesis (SOURCE-14+15).
Scapulohumeral Rhythm - smooth, quality and symmetrical movement where the Scapula contributes roughly a third of the total arm elevation
Resting Posture - of slight Scapulothoracic Joint - Elevation and Scapulothoracic Joint - Retraction is considered an optimal position for The Shoulder Girdle as it leaves the Glenoid Fossa facing slightly upwards (SOURCE-20):
Excessive Scapulothoracic Joint - Depression - may indicate hypertonicity of the Pectoralis Minor or Latissimus Dorsi or Upper Trapezius insufficiently which is often of neurogenic cause (SOURCE-8+18+19)
Scapular Winging - Medial Winging indicates Serratus Anterior insufficiency, Lateral Winging Middle/ Lower Trapezius
Scapular Tilting - excessive anterior tilting is often observed with Pectoralis Minor hypertonicity
Muscle Atrophy - of the following Scapulothoracic Muscles may indicate a nerve palsy:
Scapular Dyskinesis - see page
While Scapula motion may be passively assessed in isolation, it is most often assessed as a composite motion of The Shoulder Girdle . The most notable example of this would be arm elevation, where Scapula motion is coupled with motion at the Glenohumeral Joint and complimented by adjustments at the Sternoclavicular Joint and Acromioclavicular Joint . As a general rule, there is an approximate ratio of 2 parts Humerus movement for every 1 part Scapula movement, although this is influenced by the direction of movement and presence of dysfunction (SOURCE-23). The extent of motion available to the Scapula is as follows (SOURCE-21+22):
Rotation - approximately 45-60º of motion between Scapulothoracic Joint - Upward Rotation and Scapulothoracic Joint - Downward Rotation
Protraction-Retraction - approximately 10-12cm of motion between Scapulothoracic Joint - Protraction and Scapulothoracic Joint - Retraction
Scapulothoracic Joint - Depression - approximately 5-10º of active depression
Scapulothoracic Joint - Elevation - approximately 35-40º of elevation
As Downwards Rotation is intimately tied with motion at the Glenohumeral Joint , it may be prudent to isolate the assessment to the Glenohumeral Joint to determine its involvement. This is done by stabilising the Scapula through patient positioning (typically lying supine) or the assistance of the practitioner, where a reduction in Pain implicates the Scapulothoracic Joint. Resisted or Isometric Tests often reveal patterns of Scapular Dyskinesis (SOURCE-1). Reistance may be applied by the practitioner or with the use of light Dumbbells (SOURCE-1).
The following Shoulder - Special Tests may be relevant in the assessment of Scapulothoracic Joint dysfunction: Scapular Dyskinesis
Muscle Performance
Scapular Assistance Test
Spurling’s Test - to assess for Radiculopathy
The following muscles should be evaluated for their length:
The following tests may be conducted to rule in/out nerve contribution with C3 , C4 , C5 , C6 and C7 Nerve Roots most relevant to Scapulothoracic motion: Cervical - Myotomes (active resisted)
Cervical - Dermatomes - evaluates sensory region
C3 - skin over the posterior neck, superior shoulder and Clavicle
C5 - skin over the lateral shoulder/ Deltoid towards base of Thumb
C6 - skin over lateral arm from shoulder to Thumb and index Fingers
C7 - skin over posterior arm from shoulder to middle Fingers
Reflex - diminished reflex indicates potential lesion at corresponding Nerve Root
Upper Limb Nerve Tension Tests
Treatment of Scapulothoracic Joint dysfunction should be specific to the underlying cause. For rehabilitation of common underlying conditions such as Scapular Dyskinesis , Subacromial Impingement and Glenohumeral Instability , see their respective pages.
The following lists Stretching techniques may be relevant to the Shoulder that aim to either restore length of associated soft-tissues or correct overall biomechanics, with lists of targeted stretches for each Muscle on its respective page (seeKey Structuresabove):Simple:
Forward Elevation Stretch - rudimentary passive stretch with moderate GH Joint - Flexion range
Shoulder External Rotation Stretch - rudimentary active stretch with large GH Joint - External Rotation range and several variations
Seated Thoracic Rotation with Breathing - large lateral flexion and rotation range coupled with breathing
Genie Stretch - rudimentary horizontal adduction stretch
Intermediate:
Door Frame Neck Stretch - self-guided neck stretch with several variations
Door Frame Shoulder Stretch - self-guided anterior shoulder stretch with large Horizontal GH Joint - Abduction range
Dowel External Rotation Stretch - self-guided GH Joint - External Rotation stretch with overpressure
Sleeper Stretch - greater emphasis on GH Joint - Internal Rotation
Bent Over Lat Stretch - accessible active stretch with large GH Joint - Flexion or Horizontal GH Joint - Adduction 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
Advanced:
Shoulder Dislocates - mobility exercise that emphasises the greatest circumduction range possible
Swimmers Oblique Extensions - exercise that may be used to lengthen entire Lateral Line through large body-wide lateral-flexion range
Sleeper Stretch MWM - internal rotation stretch combined with Humerus Mobilisation
Bretzel 1.0 - wholebody 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
Jefferson Curl - maximal stretch for posterior chain with emphasis on intersegmental movment of the Vertebral Column and capacity to add load
Dead Hangs - whole body traction for Pull and Push muscles with large overhead range
Strength training forms an integral role of shoulder (p)rehabilitation and enables individuals to improve function/ capacity. Strength training of the Scapulothoracic musculature has been shown to improve position of the Scapula (SOURCE-2). While many listed exercises may be progressed through load or time under tension, the following details shoulder movements in rough order of most rudimentary to sophisticated.
Initial Phase - typically used in the early phases of (p)rehabilitation to mitigate Muscle atrophy, provoke activity and cue appropriate joint motion. Caution must be given to training volume as muscle fatigue can have adverse effects of Scapula position (SOURCE-1):
Shoulder Sling - Scapula setting exercise
Rotator Cuff Pendulums - oscillatory motion that afford a distracting glide to the Humeral Head
Prone Cobra - isometric exercise that emphasises Middle and Lower Trapezius
Rotator Cuff Banded Rotations - light low range isotonic rotation exercises
Prone Shoulder External Rotations - adds gravity or light load to Apprehension Test position
Isometric Chest Squeezes - isometric exercise that isolates Chest
Band Pull-Apart - basic isotonic exercise for Scapular Retractors
Banded Horizontal Adduction - low load isotonic horizontal adduction exercise
Side-Lying Shoulder External Rotations - maximises effect of gravity against External Rotation with upper arm fixed against torso
Standing Shoulder External Rotations - incorporates upright torso posture
Banded Unilateral Lat Activations - activate lat, posteroinferior drawer on Humerus
Bird-Dog - bodyweight isotonic exercise that emphasises Posterior Sling / Core
Circumduction Row - isotonic exercise with variable load used to emphasise mid-to-lower Trapezius
Scapular Punches - isotonic exercise that emphasises Scapulothoracic Joint - Protraction
Bottoms-Up Kettlebell Walk - isometric push/ stability exercise with or without perturbation
Chest Press Machine - rudimentary horizontal push machine
Pallof Press - low load horizontal push exercise that emphasises anti-rotation of Core
Mid-Phase - simple strength exercises that may be relevant once Pain -free motion is achieved:
Inverted Rows - rudimentary isotonic horizontal pull exercise that utilises bodyweight
Push-Up - bodyweight isotonic horizontal push exercise
Push-Up Plus - push-up variation with additional Scapulothoracic Joint - Protraction
Seated Row - rudimentary weighted isotonic horizontal pull movement
Lat Pulldown - rudimentary weighted isotonic vertical pull movement with a high range of motion
Overhead Press - isotonic vertical push exercise with large overhead range
One Arm Row - unilateral DB version of Seated Row
DB Shoulder Press - unilaterally loaded overhead press variation
Face Pulls - bilateral isotonic horizontal pull exercise that emphasises GH Joint - External Rotation
Bench Press - isotonic horizontal push exercise with capacity for high loads
Incline DB Bench Press - unilaterally loaded Bench variation on variable incline
Straight Arm Lat Pulldown - isotonic motion that emphasises Lats and straight arm strength
Front Raises - isotonic GH Joint - Flexion exercise with many variations
Side Raises - isotonic GH Joint - Abduction exercise with many variations
Bent Over Row - weighted isotonic horizontal pull exercise that emphasises entire posterior chain
Dips - bodyweight isotonic push exercise with large GH Joint - Extension range
DB Pullover - moderate isotonic movement with large overhead and Thoracic - Extension range
Chest Fly - large horizontal abduction range to emphasise lengthening of the Chest
Upright Row - weighted isotonic vertical pull exercise that emphasises Upper Trapezius and Deltoid
Shrug - weighted isotonic exercise that emphasises Scapulothoracic Joint - Elevation
Farmers Carry - upperbody/ Core isometric exercise with perturbation of walking
Late Phase - exercises at this stage should more closely reflect the activities/ demands of the patient. Relevant functional patterns should be promoted and exercises should be progressed in complexity and intensity:
Push Press - wholebody, explosive variation of the Overhead Press
DB Hang Clean - unilateral clean progression, often performed explosively
Bottoms-Up Kettlebell Walk - typically isometric exercise for entire arm musculature with perturbation from walking
Prone Lat Pulldown - Lat Pulldown variation that emphasises Thoracic - Extension
Lu Raises - large GH Joint - Abduction range with no Humerus rotation to promote Scapulothoracic Joint - Upward Rotation
Half DB Bench Press - unilateral isotonic horizontal pressing motion that emphasises the Anterior Sling
Pull-Up - bodyweight or greater load through large overhead motion
Kneeling Landmine Press - wholebody, explosive vertical pressing exercise with large overhead range
Split Stance Landmine Press - crossbody, standing variation of the Kneeling Landmine Press
DB Snatch - unilateral isotonic, explosive shoulder exercise with large overhead range
Medball Pullover Throw - plyometric Pullover variation
Medicine Ball Chest Press - plyometric horizontal pressing motion, often sports relevant
Suitcase Carry - unilateral farmers carry which emphasises crossbody functional patterns
Rope Climb - pull-up variation with entire load bestowed on alternating arm
DB Snatch to Step-Up - wholebody DB Snatch variation that emphasises diagonal functional patterns
Bird-Dog Row - One Arm Row variation that emphasises Posterior Sling
While the Scapulothoracic Joint may benefit from mobilisations of The Shoulder Girdle ’s other articulations, the following lists techniques that can be directly applied to this joint:
Joint Play - passive accessory movements performed without active movement
Mobilisation with Movement - mobilisations applied with active movement
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
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