Downwards, orMedial, Rotation of the Scapula occurs as its Inferior Angle glides in an Inferomedial direction moreso than the Superior Angle, causing the Scapula to rotate and the Glenoid Cavity to face downwards (SOURCE-3+4+6). This motion forms a natural component of returning the arm to the side from an elevated position, in coordination with the GH Joint - Adduction Muscles as consistent with Scapulohumeral Rhythm (SOURCE-4). Scapula motion is complimented by slight adjustments at the Sternoclavicular Joint and Acromioclavicular Joint which couple Downwards Rotation with Scapulothoracic Joint - Retraction and Anterior Scapular Tilting . While returning the arm to the side alludes to a rather passive process, Downwards Rotation forms a notable active participant in motions such as Pull ing exercises.
Prime movers
Stabilisers
Anterior Sling - exaggerates motion, may be Pain ful
Posterior Sling - limits motion, may be Pain ful
Lateral Arm Chain - tension restricts motion
Dorsal Arm Chain - exaggerates motion, may be Pain ful
Deep Front Arm Line - causes motion, may be Pain ful
Deep Back Arm Line - Pain ful when strained by motion
Back Functional Line - Pain ful
Front Functional Line - Pain ful
Spiral Line - limits motion
Downwards Rotation of the Scapula occurs as its Inferior Angle glides in an Inferomedial direction moreso than the Superior Angle, causing the Scapula to rotate and the Glenoid Cavity to face downwards (SOURCE-3+4+6). This motion forms a natural component of returning the arm to the side from an elevated position (SOURCE-4). Scapula Downwards Rotation is complimented by an inferior glide of the medial Clavicle at the Sternoclavicular Joint and simultaneous Downwards Rotation at the Acromioclavicular Joint (SOURCE-4). These normal arthrokinematics couple Downwards Rotation with Scapulothoracic Joint - Retraction and Anterior Scapular Tilting . Across the entire arc of Scapula Rotation (Downwards to Upwards), approximately 45-60º of motion should be available (SOURCE-6).
Typically the effect of gravity and gradual lengthening of the anatagonists such as the Upper Trapezius and Serratus Anterior are a sufficient enough force to facilitate this motion (SOURCE-5). When greater forces are required, Downwards Rotation is facilitated by the Levator Scapulae , Rhomboids and at low levels of elevation Pectoralis Minor (SOURCE-3+4+5). In The Shoulder Girdle composite motion of lowering the arm, these downwards rotators cooperate with GH Joint - Adduction Muscles (SOURCE-4).
During Shoulder Elevation the complimentary motions of the Clavicle include (SOURCE-7):
~40-50º of Anterior Rotation
~11-15º of Depression
The majority of this movement occurs at the Sternoclavicular Joint ; however, the Lateral end of the Clavicle is found to depress ~1mm and protract ~3.5mm (SOURCE-7). Similarly, at the Acromioclavicular Joint roughly 19º of Anterior Scapular Tilting occurs relative to the Clavicle , whereas an average of 31º rotation is expected at the Sternoclavicular Joint (~31º) (SOURCE-7).
Excessive Downwards Rotation and a reduction in Scapulothoracic Joint - Upward Rotation are often comparable but not always the same. Excessive Downwards Rotation of the Scapula may serve as a predisposing factor to shoulder pathology or often a compensatory attempt to regain stability in an otherwise fragile environment:
Compensation - greater Downwards Rotation during arm elevation is reported in those with Glenohumeral Instability and Rotator Cuff insufficiency (SOURCE-3). Specifically with overhead throwing athletes, common Posterior Glenohumeral Joint Capsule laxity often presents with excessive Downwards Rotation (SOURCE-1). While this increase in Downwards Rotation may represent a distinct response to pathology, the more commonly described decrease in Upwards Rotation is thought to be a compensatory response to prioritise stability over movement. A reduction in Upwards Rotation and increase in Internal Rotation orients the Glenoid in a way that mitigates stress on the Anterior Glenohumeral Joint Capsule and excessive excursion of the Head of Humerus (SOURCE-9). If a response of excessive Downwards Rotation is indeed distinct from a reduction in Upwards Rotation, it may be attributed to laxity which simply allows the Scapula to drift (SOURCE-1)
Predisposing Factor - a failure to adequately lift the Acromion during arm elevation predisposes The Shoulder Girdle to Subacromial Impingement and its associated cascade. Although inconsistent as impingement may derive from several mechanisms, a reduction of Upwards Rotation is a common association with impingement that is thought to be causative (SOURCE-9)
The Pectoralis Minor may lead to greater Anterior Scapular Tilting and Downwards Rotation when hypertonic (SOURCE-3). A similar pattern of increased tilting and rotation is associated with Thoracic Spine Kyphosis (SOURCE-3).
The primary restraint for Downwards Rotation is the eccentrically contracting Serratus Anterior , while at the limits of motion the Conoid Ligament forms static restraint (SOURCE-6). Hypertonicity in the other predominant Scapulothoracic Joint - Upward Rotation Muscle , the Upper Trapezius , may also limit Downwards Rotation and predispose Subacromial Impingement as it leads to a superior migration of the axis point of rotation of the Glenohumeral Joint (SOURCE-8).
Both excessive and insufficient Downwards Rotation are common forms of Scapular Dyskinesis of which there may be many causes. In terms of movement, the literature often refers to excessive downwards rotation as reduced Scapulothoracic Joint - Upward Rotation . While the two are not entirely synonymous, this perspective affords a more complete understanding of the relation between Downwards Rotation dysfunction and various pathologies.
Scapular Dyskinesis - altered Upwards Rotation of the Scapula at rest or during movement is a telltale sign of Dyskinesis. Scapular Winging is a common subtype of Dyskinesis that is most often associated with insufficiency from the Serratus Anterior , one of the prime-movers of Upwards Rotation (SOURCE-10). Weakness in the Serratus Anterior and/or Middle/Lower Trapezius fails to sufficienctly lift the Acromion during arm elevation, disturbing kinematics at both the Scapulothoracic Joint and Glenohumeral Joint to predispose several pathologies (SOURCE-1+8+11). Conversely, heightened activity of the Upper Trapezius relative to the Lower Trapezius may lead to a higher axis point of rotation for the Glenohumeral Joint and consequently predispose impingement (SOURCE-8). In addition to a strength discrepancy between fibres, altered recruitment patterns may implicate the Trapezius in impingement. (SOURCE-8). Hypertonicity of Downwards Rotators such as the Pectoralis Minor may lead to increased Downwards Rotation at rest and restricted Upwards Rotation during movement (SOURCE-3).
Glenohumeral Instability - derived from both capsular laxity and muscular insufficiency often display excessive Downwards Rotation of the Scapula . Greater Downwards Rotation during arm elevation is often seen with Rotator Cuff pathology (SOURCE-3). At rest, overhead throwing athletes with laxity in the Posterior Glenohumeral Joint Capsule often display increased Downwards Rotation (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-12+13). This may be a compensatory response to prioritise stability over mobility and ensure the Glenoid is appropraitely oriented (SOURCE-9).
Subacromial Impingement - excessive Downwards Rotation may impede the natural Scapulohumeral Rhythm by limiting the ability of the Acromion to elevate during arm elevation, causing the Humerus to be obstructed under the coracoacromial arch. Through a diverging mechanism, increased Upwards Rotation has also been associated with impingement. Heightened activity of the Upper Trapezius relative to the Lower Trapezius lead to a superior migration of the Glenohumeral Joint ’s axis of rotation which predisposed impingment (SOURCE-8)
Thoracic Spine Kyphosis - is associated with an increase in downwards rotation which may predispose several should pathologies including Subacromial Impingement and Scapular Dyskinesis (SOURCE-2)
Nerve Palsy - compromise of the innervating nerves may impede muscle performance of the Downwards Rotators:
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-18)
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-16+17). This may lead to weakness, chronic Pain and atrophy of the Pectoralis Major and/or Pectoralis Minor (SOURCE-17)
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-14+15)
The extent of Downwards Rotation of the Scapulothoracic Joint can be observed at rest and through motion:
Scapulohumeral Rhythm - reduced Scapulothoracic Joint - Upward Rotation
Exaggerated or Premature Downwards Rotation of the Scapula when arm is loaded with resistance
Increased slope of The Shoulder Girdle on the symptomatic side where the shoulder appears depressed
Downwards Rotation of the Scapula is typically assessed as part of the arms full arc of motion to determine its deviance from normal Scapulohumeral Rhythm . Over this arc approximately 45-60º of Scapula Rotation should occur, although this vary between planes of elevation (SOURCE-6). Attention should be given for signs of Scapular Dyskinesis , including premature or insufficient Scapulothoracic Joint - Upward Rotation , which may refine differential diagnosis.
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 . As gravity and relaxing upwards rotators may sufficiently produce Downward Rotation, Isometric Tests may be used to determine involvement of the prime movers.
The following Shoulder - Special Tests may be relevant in the assessment of dysfunctionalDownwards Rotation: Muscle Performance
Shoulder Flexion Resistance Test - to assess Pectoralis Minor or Serratus Anterior contributions
Scapular Assistance Test
Spurling’s Test - to assess for Radiculopathy
The following tests may be conducted to rule in/out nerve contribution with C4 , C5 , C6 and C7 Nerve Roots mst relevant to Scapulothoracic Joint Downwards Rotation: Cervical - Myotomes (active resisted)
Scapulothoracic Elevation ( Shrug ) - Cranial Nerve XI and C4
Scapulothoracic Joint - Retraction - C5 and Dorsal Scapular Nerve
Punch Out Test - C5 , C6 , C7
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
Reflex - diminished reflex indicates potential lesion at corresponding Nerve Root
Upper Limb Nerve Tension Tests
The treatment of Scapulothoracic Joint Downwards Rotation dysfunction should be specific to the underlying cause. For rehabilitation of common underlying conditions such as Scapular Dyskinesis , Glenohumeral Instability or Subacromial Impingement , see their respective pages.
The following Stretching techniques may directly or indirectly improve Scapulothoracic Joint Rotation restriction:
Forward Elevation Stretch - rudimentary passive stretch with moderate GH Joint - Flexion range
Door Frame Shoulder Stretch - self-guided anterior shoulder stretch with large Horizontal GH Joint - Abduction range
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
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
Wheel Pose - full bridge variation that lengthens entire anterior chain
Dead Hangs - whole body traction for Pull and Push muscles with large overhead range
As a specific training protocol relates to the underlying cause of Scapulothoracic Joint Downwards Rotation dysfunction, the following lists rotation-based Strength exercises in rough descending order from most rudimentary:
Prone Cobra - isometric exercise that emphasises Middle and Lower Trapezius
Deep Neck Flexor Endurance Test - performed as an exercise if Forward Head Posture present
Scapular Punches - isotonic exercise that emphasises Scapulothoracic Joint - Protraction
Bottoms-Up Kettlebell Walk - isometric push/ stability exercise with or without perturbation
Push-Up Plus - push-up variation with additional Scapulothoracic Joint - Protraction
Lat Pulldown - rudimentary weighted isotonic vertical pull movement with a high range of motion
Overhead Press - isotonic vertical push exercise with large overhead range
DB Shoulder Press - unilaterally loaded overhead press variation
Straight Arm Lat Pulldown - isotonic motion that emphasises Lats and straight arm strength
Side Raises - isotonic GH Joint - Abduction exercise with many variations
DB Pullover - moderate isotonic movement with large overhead and Thoracic - Extension range
Push Press - wholebody, explosive variation of the Overhead Press
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
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
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
While there is a capacity for any Mobilisations of The Shoulder Girdle or Cervical Spine to treat dysfunctional Downwards Rotation, the following list those that are most likely: Joint Play
Cervical Spine - for instances of Radiculopathy a PACVP , PAUVP or TVP may be applied to relevant Cervical segment(s) in addition to the following techniques:
Thoracic Spine - mobilisations of the upper segments may improve symptoms of shoulder dysfunction, where a rounded shoulder posture is present (SOURCE-19):
Mobilisation with Movement - mobilisations with active movement
Shoulder - MWM 1 - Scapulothoracic Elevation, GH Abduction, Flexion or Scaption
Shoulder - MWM 2 - Scapulothoracic Elevation, GH Abduction, Flexion or Scaption
Shoulder - MWM 3 - (mid-range) GH Abduction or Flexion
Shoulder - MWM 4 - (mid-range) GH Abduction, Flexion or Scaption
AC Joint - MWM 1 - GH Flexion or Horizontal Adduction
Cervical Spine - for suspected Radiculopathy , the following techniques may be indicated:
SMWAM - Cervical mobilisations with arm movement
Neurodynamic SMWAM - Cervical mobilisations with neurodynamic arm movement
Cervical SNAGS - Cervical mobilisations with neck movement
NAGS - particularly useful for restriction or Pain associated with movement for C2-C7
Thoracic Spine - mobilisations of the upper segments may improve symptoms of shoulder dysfunction, where a rounded shoulder posture is present (SOURCE-19)
Reverse NAGS - particularly useful for pain or restriction associated with movement of the Upper Thoracic region
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