Scapular Dyskinesis

• Ian S Rice MD
Muscles of the Scapula
Pec Minor
Coracobrachialis
Biceps (short head)
Biceps (long head)
Serratus Anterior
Triceps (long head)
Subscapularis
Rhomboid Major/Minor
Levator Scapulae
Trapezius
Deltoid
Supraspinatus
Infraspinatus
Teres Major
Teres Minor
Latissimus Dorsi
Omohyoid
Infraspinatus
Max cross sectional area

1.8 to 9 times larger compared to supraspinatus and teres

minor

High eccentric loading during overhead pitching

Shortens and limits glenohumeral internal rotation and

horizontal adduction ROM

Associated with tightness of posterior shoulder structures

Infraspinatus Function
Produce glenohumeral joint compression

Create a downward pull on the humeral head

to minimize superior migration

Decelerator during overhead throwing

motion
Resists shoulder internal rotation and horizontal
adduction
Pec Minor

Short and tight

Increased scapular internal rotation and anterior
tilting
Scapula Winging

Lateral Winging
Medial Winging
Medial Winging
Deficit of Serratus Anterior

Innervated by long thoracic nerve

Caused by repetitive stretch, compression, scapula fx, laceration of

nerve

Inferior border of scapula goes medial

Treatment:

Nonop - observe for 6 months for return of nerve function

Operative - pec major transfer with fascia lata graft

Lateral Winging
Deficit of trapezius

Spinal accessory or Dorsal scapular nerve

Iatrogenic - ex. dissection for lymph nodes

Inferior border of the scapula goes lateral

Treatment

Eden-Lange transfer

Lateralize insertion of levator scapulae and rhomboids

Stages of Throwing
Wind Up

Minimal force
through the shoulder
Inactive rotator cuff
muscles
Development of torso
and leg force
Early Cocking

Peak Deltoid activation

Late Cocking
Peak muscle activation: Supra/infraspinatus, teres minor

High torque phase: max external rotation of shoulder

Glenohumeral internal rotation deficit

Internal impingement
Acceleration
Triceps activation

Pec major, lat dorsi, serratus anterior activation

At ball release - 4 body motions

Trunk rotation, shoulder internal rotation, elbow extension,

wrist flexion

20% reduction in trunk kinetic energy requires 33% more

velocity or 70% more mass at distal segments to maintain
same energy at ball impact
Deceleration

Eccentric contraction
of all muscles to
counter torque and
slow arm motion
Follow Through

Distraction forces
must be resisted by
posteroinferior
capsule
Development of “Dead Arm”
Overhead athlete first develops tightness in back of the shoulder

Posteroinferior capsular contracture

Causes a posterosuperior shift in glenohumeral rotation point

Peel back forces in late cocking causes a SLAP lesion

Mechanical symptoms dictate surgical treatment

Hyperexternal rotation of the humerus increases the clearance of the greater

tuberosity over the glenoid and reduces the humeral head cam effect on
anterior capsule

Scapular protraction develops

Pathoanatomy of “Dead Arm”
External rotation forces causes repetitive
“microtrauma” to the anterior capsule

Hyperexternal rotation and hyperhorizontal

abduction

Loss of internal rotation in abduction

Less than the external rotation gain

Caused by posterior inferior capsular

contracture

Impingement itself is not pathologic

All shoulders with in abduction with external

rotation show impingement
Glenohumeral internal rotation deficit
(GIRD)
Definition: Degree loss of internal rotation

Measured with shoulder abducted in plane of the body and scapula stabilized by
downward pressure to the anterior shoulder

Measure to the point where the scapula moves on the posterior chest wall
Tethered Shoulder

Posterior capsule contraction

Posterior band of the IGHL exerts a posterosuperior

force on the humeral head

Glenohumeral contact point is shifted and can have more

external rotation before impingement

Cam effect of the humeral head and proximal humeral

calcar on the anteroinferior capsule is reduced by the
shift
Development of a SLAP Tear
Tight posteroinferior capsule and
GIRD develop increased peel-
back forces and increased shear
forces on the labrum

Peel back occurs due to bicep

tendon vector shifting to a more
posterior position in late cocking.

Torsional force to rotate

medially over corner of glenoid
Role of the Scapula

Link between trunk and arm

Transfers and increases the energy, power,
and equilibrium from lower extremities and
trunk
Kinetic Chain Theory
Kinetic Chain

Coordinated sequencing of multiple segments to

maximize power

Legs and trunk act as force generators

Shoulder acts a funnel and force generator

Arm acts as a force delivery mechanism

Only 50% of velocity is developed from the

arm/shoulder
Kinetic Chain: Legs and Trunk
Provides rotational momentum for force generation

Able to generate 50-55% of total force and kinetic

energy in a tennis serve

Weakness in hip abductors or trunk flexors increases

lumbar lordosis during arm acceleration

Hyperabduction/external rotation position at the

shoulder and increases posterior compression loads
Kinetic Chain: Scapula
Retracts and protracts around
the thoracic wall during the
throwing motion

Moves with humerus to avoid

hyperangulation of humerus
on glenoid
The Cascade
Acquired posteroinferior capsule contracture

Max shear stress on posterosuperior labrum

Inferior axillary pouch structures are imbalanced

Posterosuperior shift of humeral head

Shear forces at biceps anchor and posterosuperior labral attachment

increase

Anterior capsule structures become lax

Excessive external rotation caused by GIRD leads to increased shear and

torsional stress in the posterosuperior rotator cuff
Causes of Dyskinesis
Bony causes

Thoracic kyphosis

Clavicle fracture non-union or shortened malunion

Joint causes

AC instability or arthrosis

GH joint internal derangement

Neurological causes

Cervical radiculopathy

Long thoracic or spinal accessory nerve palsy

Soft Tissue causes

Stiffness of pec minor or short head of biceps —> anterior tilt and protraction

GIRD —> reduced humeral head internal rotation and horizontal abduction
Identifying “shoulder at risk”
Shoulders with:

Glenohumeral internal rotation deficit

Malpositioned SICK scapula

Anatomy

Posterosuperior labrum

Posterior supraspinatus tendon

Anterior inferior capsular structures

 Clinical Clues

Medial and inferior scapular borders for

winging or prominence
Lack of smooth coordinated movement as
exemplified by early scapular elevation
Shrugging during ascending arm forward
flexion and rapid downward rotation during
arm lowering from full flexion
Scapular Assistance Test

Assisting scapular upward rotation

by manually stabilizing upper
medial border and rotating the
inferomedial border as arm is
abducted
•
Positive result
–
Relief of impingement
symptoms and weakness
Scapular Retraction Test
•
Manually positioning and
stabilizing the entire medial
border of the scapula
•
Positive
–
Increased muscle strength
–
Decreased pain with Jobe
relocation test
SICK Scapula
•
Scapular malposition
•
Inferior medial border prominence
•
Coracoid pain and malposition
•
dysKinesis of the scapular movement

•
Clinical Presentation
–
Anterior shoulder pain (coracoid) , posterosuperior scapular pain, superior
shoulder pain, proximal lateral arm pain
–
Inferior position, lateral displacement, abduction
SICK Scapula
•
Coracoid pain with passive forward
flexion
–
Pec minor & short biceps tendon
“tightness”
•
Lowers leading edge of acromion
causing impingement from
anteroinferior angulation
–
Levator scapulae is placed under
tension when scapula tilts and rotates
laterally
•
Decreased subacromial space
Patterns of Dyskinesis
•
Type I - inferior medial scapular border
prominence
•
Type II - medial scapular border prominence
•
Type III - superomedial scapular border
prominence
Poor posture
•
Prolonged sitting tasks leads to forward head posture, increased thoracic kyphosis, and
protraction of shoulder girdle
–
Reduced clavicle retraction
–
Increased clavicle elevation
–
Scapular upward rotation
–
Scapular posterior tilt
•
Slouched posture affects scapular orientation, shoulder muscle strength and ROM
–
Altered serratus anterior muscle activity
–
Force imbalance in upper and lower trapezius muscle
–
Flexibility deficits (pec minor tightness, posterior glenohumeral capsular stiffness)
Dyskinesis and Neck Pain
•
No consensus about relationship
•
Noted to be a risk factor for shoulder pain
–
Possible predisposition to develop shoulder pain, and
then is exacerbated by it
•
Typical finding of bilateral scapular dyskinesis in
patients with shoulder pain
–
Worse on affected side
Rehabilitation
•
Need to determine patient goals
–
Office worker: correction of axioscapular muscles,
scapular orientation with arms by the sides, and
during prolonged upper limb activities
–
Overhead Athletes: advanced scapular muscle
control and strength in sport specific movements
•
Need to address whether flexibility deficits are primary or secondary
–
If flexibility is the issue, then address that prior to motor control learning
Rehab of Flexibility Defects
•
Scapular level
–
Pec Minor and Levator Scapulae
–
Scapular retraction in 30 deg of flexion
•
Largest change in pec minor length
•
Glenohumeral Level
–
Posterior shoulder structures, capsule, external rotator muscles
–
Sleeper stretch
Sleeper Stretch

90% of throwers with symptomatic GIRD (greater than 25

deg) will respond to stretching.
Acceptable: less than 20 deg or less than 10% of total
rotation in non throwing shoulder.
Period of time: 2 weeks
Rehab of Muscle Motor Control
•
Neuromuscular deficits (lack of co-contraction
and force couple activity)
–
Upper Trap hyperactivity
•
Strength deficits
–
Serratus anterior, Middle and Lower Trap
Conscious Muscle Control
•
Activating Lower Trap
–
Patient palpates coracoid and then focuses on “pulling the coracoid from
his finger and moving the scapula backwards”
–
Creates posterior tilt and upward rotation
•
Counters a SICK scapula
•
Spinal Posture Correction
–
Neutral lumbopelvic posture, with correction of scapulothoracic and
cervical postures
–
“Occipital lift” of the head
Muscle Control and Strength
•
Open Chain Exercises
–
Low Row, Inferior Glide, Lawnmower
•
Closed Chain Exercises - require less activation than open chain
–
Pushing hands on thighs in upright sitting, Wall sliding exercise, Pushups
•
Want exercises with low Upper Trap/Lower Trap, Upper Trap/Middle Trap, and Upper Trap to Serratus Anterior ratios
–
Support the arm (wall slide and bench slide exercises)
•
Intramuscular Trapezius training
–
Side lying external rotation, side lying forward flexion, prone horizontal abduction with external rotation and prone
extension
•
Early activation of lower trapezius
–
Diagonal patterns including lower limb and core muscle activity favor scapular muscle activity (lower trapezius)
Low Row

•
Trunk extension,
scapular retraction,
arm extension as
patient pushes
posteriorly
Wall Washes
Advanced Sports Movements
•
Last stage of rehab
–
Goal: exercise advanced scapular muscle control and strength
•
Attention to integration of the kinetic chain into the exercise
program, plyometric and eccentric exercises
–
Throwers use weight balls and elastic resistance tubing
–
Swimmers should focus on exercises while prone
•
W-V exercise
•
Total Time: 12 weeks to 6 months
Summary
•
Posterior inferior capsular contracture
–
Leads to GIRD
•
Then posterior superior cuff internal impingement
–
Which develops posterosuperior SLAP tear
»
Resulting in Anterior capsular stretching
•
Scapular protraction
OITE
•
23 yo professional pitcher complains of posterior shoulder pain. Physical
exam is notable for scapular dyskinesis. No intra-articular pathology is found
on shoulder MRI. Which of the following should be emphasized in the initial
stages of rehabilitation?
–
1) Isometric shoulder exercises
–
2) Isokinetic shoulder exercises
–
3) Closed chain shoulder exercises
–
4) Coordination of scapular motion with trunk and hip movements
–
5) Axial loading shoulder exercises
4
•
Scapular dyskinesis is an alteration in the normal motion of the scapular during
coordinated scapulohumeral movements. It occurs as a sequela of prior
shoulder injury, especially injuries disrupting the activation patterns of scapular
stabilizing muscles. Kibler et al outlined a rehabilitation protocol to treat
scapular dyskinesis. The principle is to treat the problem proximal to distal. The
first stage involves attaining full motion of the scapular and coordinating the
scapula with trunk and hip motions. Once this has been achieved, the second
stage involves strengthening the scapular musculature. As scapular control is
attained, exercises are introduced that place emphasis on the shoulder and arm
beginning with flexibility and closed-chain strengthening, eventually working up
to sport-specific functions. Progress is determined by functional improvement
rather than a strict time table.