All Things Scapular (Scapular Dysfunction, Evaluation, & Interventions)

Question 1

Scapular Dysfunction/Dyskinesia:

• Classifications

All Things Scapula

Answer 1

Scapular Dysfunction/Dyskinesia:

Classifications:

• Scapular Dyskinesia
• SICK Scapula
• Seen/Associated with RTC dysfunction and Labral Instability diagnosis

Question 2

Scapular Dysfunction/Dyskinesia - Characteristics:

• Features of Scapular Dyskinesia = ?
• Risk Factors = ?
• Observation = ?
• Examination = ?

All Things Scapula

Answer 2

Scapular Dysfunction/Dyskinesia - Characteristics:

(a) Features of Scapular Dyskinesia:

• Altered position, biomechanics, and motion of scapula.
• May reduce subacromial space and RTC strength.
• Dysrhythmias include asymmetry, hitches, and jumps in scapular movement.

(b) Risk Factors:

• Pec tightness, posterior capsule tightness, GERD
• Serratus weakness
• Mid and low trap weakness
• Overhead activities
• Nerve damage
• Core weakness
• GH/shoulder girdle injuries

(c) Observation:

• Downward tilting of scapula
• Winging of inferior angle
• Winging of medial boarder
• Possible limited scapular upward mobility.
• Kyphotic Posture or limited thoracic mobility.

(d) Examination:

• (+) Static scapular positional measurements
• Scapular assistance test
• Scapular retraction test
• Push up test

Question 3

Scapular Dysfunction/Dyskinesia - Manual Therapy:

• Joint Mobilization = ?
• STM/MFR = ?
• PNF = ?

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Answer 3

Scapular Dysfunction/Dyskinesia - Manual Therapy:

(a) Joint Mobilization:

• Scapular Mobilizations
• Manual Scapular Assistance
• SC joint mobilizations
• Inferior/Posterior, Tractional GH mobilizations
• Cervical & Thoracic mobilization
• Hyper or Painful = I/II
• Hypo = III/IV/V

(b) STM/MFR:

• Cross Frictional Pin and Stretch to RTC, Pecs/Traps

(c) PNF:

• PNF diagonal ROM/stretching
• Multiple angle isometrics with humeral head control/centering.
• Contract relax stretching for improved mobility utilizing PNF.
• Increase speed with PNF for quick reversals from muscle groups and multiplanar activities.

Question 4

Scapular Dysfunction/Dyskinesia - Therapeutic Exercise:

• Motor = ?
• Sensory = ?

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Answer 4

Scapular Dysfunction/Dyskinesia - Therapeutic Exercise:

(a) Motor:

• Serratus and Trapezius strengthening
• Pec Minor flexibility
• Close chain followed by open chain scapular control
• Scapular mobility for improved upward rotation
• Shoulder IR flexibility
• Core Strengthening
• Posterior Capsule mobility
• RTC Strengthening endurance/reactivation
• Isometrics, Theraband isotonics, weights, single plane progressing to multiple plane endurance

(b) Sensory:

• Postural reeducation
• Scapular awareness position sense
• Mirror feedback training for movements
• Body blade
• Rhythmical stabilization
• Undermining/challenging postural stability as progression

Question 5

What does Scapular Dysfunction sound like in a patient interview = ?

All Things Scapula

Answer 5

Scapular Dysfunction sound like in a patient interview:

(a) Altered shoulder blade positioning and movement.

However…

(b) It also often it sounds like other types of shoulder problem:

• Impingement signs
• Labral pathologies
• RTC dysfunction
• Pitching dysfunction
• Thoracic abnormalities

Question 6

Scapulohumeral Rhythm = ?

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Answer 6

Scapulohumeral Rhythm:

Question 7

Normal Scapular mechanics = ?

All Things Scapula

Answer 7

Normal Scapular mechanics:

Question 8

Active Movements = ?

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Answer 8

Active Movements:

• We want symmetrical motion that matches the relative movement of the humerus without winging or tilting.
• We want to see the scapula move up and not be fixated
• Watch the movement, especially of the scapula, in the ascending and descending phases of abduction.
• Commonly, weakness of the scapular control muscles is more evident during descent, and an instability jog, hitch, or jump may occur when the patient loses control of the scapula.

Question 9

SICK Scapula:

• What is it = ?
• Signs & Symptoms = ?

All Things Scapula

Answer 9

SICK Scapula:

• Scapular Malposition
• Inferior Medial Prominence
• Coracoid Pain
• Dyskinesis movement

Question 10

Scapular Dyskinesia

All Things Scapula

Answer 10

Scapular Dyskinesia:

• Abnormal movements of the shoulder blade. Also sometimes called “Sick Scapular Syndrome.”
• Variety of causes most of which are attributed to errors in timing and rhythm of muscular activations .

Question 11

Scapular Winging:

• Primary = ?
• Secondary = ?
• Dynamic = ?

All Things Scapula

Answer 11

Scapular Winging:

(a) Primary scapular winging:

• Due to muscle weakness of one of the scapular muscle stabilizers.

(b) Secondary scapular winging:

• Normal movement of scapula is altered because of pathology in glenohumeral joint.

(c) Dynamic scapular winging:

• May be due to lesion of the long thoracic nerve affecting serratus anterior, trapezius palsy (spinal accessory nerve), rhomboid weakness, multidirectional instability, voluntary action, or a painful shoulder resulting in splinting of the glenohumeral joint, which in turn causes reverse scapulohumeral rhythm.

Question 12

Describe the quality of the movement in the scapula = ?

All Things Scapula

Answer 12

Quality of the movement in the Scapula:

• Does it have a Dysrhythmia?
• Asymmetry?
• Does it have a sudden jerk or position change?
• At what position of shoulder elevation does it display winging or medial prominence
• Is the dyskinesia noted more during concentric or eccentric activities.

Question 13

Causes of Scapular Imbalance Patterns = ?

All Things Scapula

Answer 13

Scapular Imbalance Patterns:

(a) Increased protraction:

• Tight pectoralis minor
• Weak/lengthened lower trapezuis
• Weak/lengthened serratus anterior

(b) Increased depression:

• Weak upper trapezuis

(c) Loss of scapular stabilization:

• Early/excessive protraction
• Early/excessive lateral rotation of scapula
• Early/excessive elevation of the scapula
• Tight lateral rotators
• Secondary impingement

Question 14

Scapular winging faults = ?

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Answer 14

Scapular Winging Faults:

(a) On concencentric elevation:

• Long/weak serratus anterior

(b) On eccentric forward flexion:

• Overactive rotator cuff
• Underactive scapular control muscles

(c) Tilting of inferior angle:
* Tight pectorlis minor
* Weak lower trapezuis

Question 15

Tests for Scapular Movement Dysfunction include = ?

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Answer 15

Tests for Scapular Movement Dysfunction include:

• Static Measurements of Scapular positioning
• Scapular assistance test
• Scapular retraction test
• Wall pushup test

Question 16

Three static (postural) measurements of scapular dysfunction = ?

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Answer 16

Three static (postural) measurements of scapular dysfunction:

1. Inferiority of superior medial scapular angle compared to the opposite side.
2. Lateral displacement measured from the superior medial scapular angle from spine.
3. Abduction of the medial boarder in degrees from vertical vs the measurement of the opposing side.

Question 17

Scapular Assistance Test = ?

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Answer 17

Scapular Assistance Test:

• Have the patient perform forward flexion/elevation.
• Compare that unassisted movement to an assisted movement
• The examiner assist the patient by promoting normal scapular mechanics by stabilizing the upper scapular border and assisting upward rotation of the inferomedial border.
• If the patient has less pain with flexion this is which is diagnostic for scapular dyskinesis

Question 18

Wall Pushup Test = ?

All Things Scapula

Answer 18

Wall Pushup Test:

• Patient does 10-15 pushups. Winging will most likely show up within the first 5-10 reps.
• Quality of movement or the presences of scapular dyskinesia is noted.

COR Video

Question 19

Athletes with scapular dyskinesis have greater risk of = ?

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Answer 19

Athletes with scapular dyskinesis have a greater risk of developing shoulder pain than those without scapular dyskinesis.

43%

Question 20

Scapular Rehab:

• Realize in most cases scapular rehab is utilized to address = ?
• Try to normalize = ?
• Address the = ?

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Answer 20

Scapular Rehab:

(a) Realize in most cases scapular rehab is utilized to address other pathologies (i.e. labral, RTC tears, impingement etc.) rather than scapular dyskinesia in isolation.

(b) Try to normalize rhythms so they are symmetrical.

(c) Address the deficits:

• medial boarder winging needs serratus strengthening
• anterior tilting needs pec minor stretching
• Excessive abducted scapula needs mid and low trap strengthening
• Downward rotated scapula need upper trap strengthening

(d) Don’t expect abnormal motor patterns to go away quickly. They take proper cueing and good kinesthetic awareness to correct.

(e) The scapula needs to move sufficiently and smoothly and have sufficient muscular support.

Rehab Ideas

• Address the hardware
• Address the software
• Stretch pecs & strengthen traps and serratus etc.
• Retrain movements for better motor control.

Question 21

Scapular PNF:

• PNF AE-PD (D1 Pattern) Indications = ?

All Things Scapula

Answer 21

PNF AE-PD (D1 Pattern) Indications:

• Weakness in flexion
• Poor scapular control
• Poor GH control in flexion
• Shoulder warm-up

Question 22

Scapular PNF: Anterior Elevation – Posterior Depression

• Indication = ?
• Goal = ?
• Technique = ?

All Things Scapula

Answer 22

(a) Indication:

• This technique is used for patients experiencing shoulder restriction in flexion or D1 functional elevation.

(b) Goal:

• Improve Neuromuscular Control of the Shoulder.

(c) Technique:

• The patient is positioned in side-lying.
• Their body is aligned and their elbow is at their side.
• Resistance to Anterior Elevation is applied hand-over-hand to the lateral shoulder (7:00).
• Resistance to Posterior Depression is applied hand-to-hand over the scapula (1:00).
• Progress from Mobility > Stability > Controlled Mobility

Question 23

Scapular PNF:

• PNF PE-AD (D2 Pattern) Indications = ?

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Answer 23

PNF PE-AD (D2 Pattern) Indications:

• Weakness in abduction
• Poor GH control in abduction
• Poor scapular control
• Shoulder warm-up

Question 24

Scapular PNF: Posterior Elevation – Anterior Depression

• Indication = ?
• Goal = ?
• Technique = ?

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Answer 24

Scapular PNF: Posterior Elevation – Anterior Depression

(a) Indication:

• This technique is used for patients experiencing shoulder restriction in abduction or D2 functional elevation

(b) Goal:

• Improve Neuromuscular Control of the Shoulder

(c) Technique:

• The patient is positioned in side-lying
• Their body is aligned and their elbow is at their side.
• Resistance to Posterior Elevation is applied hand-over-hand to the lateral shoulder (5:00).
• Resistance to Anterior Depression is applied with equal pressure anterior and posterior over the scapula and humerus (11:00).
• Progress from Mobility > Stability > Controlled Mobility.

Question 25

Take Home Message about the Scapula | *Flip and Read*

Answer 25

**Take Home Message about the Scapula**: (**a**) The scapula should be a large focus (not an after thought) when treating most shoulder conditions (i.e., RTC or Labral diagnosis). (**b**) While many of our scapular PT interventions are working on flexibility & strength realize that ultimately, we want better movement and control. (**b.1**) Work on the fundamental components and then put them all together with motor control activities that produce more normalized scapular rhythms/movement. * Winging/tipping: try to balance the musculature. * Hitches/jerking/loss of control with lowering: work on scapular motor control. * Inflexibilities and limited mobility: mobilize the scapula and surrounding musculature. (**c**) The thoracic spine & C-spine both have major influences on the scapula so make sure to address any spinal limitations.

Question 26

Which of the following is correct regarding the scapular connection to shoulder pathologies **?** **1.** Scapular immobility may contribute to shoulder impingement. **2.** Scapular dyskinesia (movement irregularities) may a sign of internal joint pathologies. **3.** Inferior angle prominance indicated pectoral tightness. **4.** Medial board prominance indicates serratus weakness. **5.** Excessive protraction of the scapula indicates mid trap weakness. **6.** All of the above

Answer 26

Which of the following is correct regarding the scapular connection to shoulder pathologies: 1. Scapular immobility may contribute to shoulder impingement. 2. Scapular dyskinesia (movement irregularities) may a sign of internal joint pathologies. 3. Inferior angle prominance indicated pectoral tightness. 4. Medial board prominance indicates serratus weakness. 5. Excessive protraction of the scapula indicates mid trap weakness. 6. **All of the above**