The scapula serves many roles in order for proper shoulder function to occur.
These roles include providing synchronous scapular rotation during humeral motion, serving as a stable base for rotator cuff activation and functioning as a link in the kinetic chain.
Each role is vital to proper arm function and can only occur when the anatomy around the shoulder is uncompromised.
The presence of bony and soft tissue injury as well as muscle weakness and inflexibility can alter the roles of the scapula and alter scapular resting position and/or dynamic motion.
This altered scapular position/movement has been termed ‘scapular dyskinesis’.
Although it occurs in a large number of shoulder injuries, it appears that scapular dyskinesis is a non-specific response to a painful condition in the shoulder rather than a specific response to certain glenohumeral pathology.(1)
Is scapular winging same as dyskinesia?
One of the other terms used for SD is scapular winging, but it is a different condition that results in scapular dyskinesia usually after a long thoracic or spinal accessory nerve injury.
Movements of Scapula(2)
Motions | Translations | Patterns |
Upward/downward rotation | Upward/downward sliding on the thorax | Protraction |
Internal/ external rotation | Medial/lateral sliding around the curvature of the thorax. | Retraction |
Anterior/posterior tilt | | Shrug(2) |
Reasons for alterations in scapular motion:
Alterations in scapular motion can be caused by fatigue, neurologic dysfunction (eg, long thoracic, accessory, or dorsal scapular nerve palsies), or inhibition by intra-articular glenohumeral or subacromial processes (eg, subacromial impingement, rotator cuff pathology, internal impingement, labral injury, glenohumeral instability, glenohumeral arthritis, and adhesive capsulitis).(3)
Conflicts:
Many authors assert that abnormal scapular motion, so-called dyskinesis, is related to shoulder injury, but evidence from 3-dimensional measurement studies regarding this relationship is mixed.(4)
Literature varies on whether it represents a cause or symptom of shoulder pathology,
The association between scapular dyskinesis and shoulder pathology is uncertain—whether it represents a cause or effect of the pathology.(3)
Scapular dyskinesis has been considered a risk factor for athletic shoulder injury; however, findings in the prospective literature have demonstrated mixed results. Latest study shows that scapular dyskinesis was not significantly associated with the development of shoulder injury in athletes.(5)
Classification
Based on visual observation, one of the four types can be determined during arm movements in terms of the presence of SD:
Type 1: Inferior angle prominence,
Type 2: Medial border prominence,
Type 3: Excessive superior border elevation,
Type 4: Absence of SD, symmetric scapular motion(2)
Identifying Scapular Dyskinesia
Clinical identification of scapular dyskinesis is difficult and relies primarily on visual observation(3)
According to Kibler et al No commonly accepted terminology presently exists for describing the abnormal dynamic scapular movement patterns that are commonly associated with shoulder injury. A method of observation was devised for clinical evaluation of scapular dysfunction, where scapular movement patterns were used.(6)
The causes
These are: shoulder, neck or posture related.
Shoulder related includes shoulder pathologies.
Neck-related :Mechanical neck pain syndromes and cervical nerve root-related syndromes. [16]
Posture-related: Excessive thoracic kyphosis and cervical lordosis, which are the changes that athletes are more tend to show are related causes of SD.(2)
Treatment
In SD, proximal and distal causative factors can be identified.
Proximal factors may include the weakness of the scapular muscle, lower trapezius, and serratus anterior.
Distal factors may include joint internal imbalance such as labral tears, GH instability, acromioclavicular separation.
Proximal factors are usually manageable with rehabilitation, while distal ones need a surgical approach followed by proper rehabilitative protocols.(7)
Conservative treatment in SD cases aims to restore scapular retraction, posterior tilt, and ER.
Specific exercises for scapular rehabilitation include flexibility exercises to decrease scapular traction, and scapular stabilization exercises to optimize scapular kinematics.
The traction on scapular posture can be reduced by performing exercises that increase muscle flexibility. Stretching exercises with shoulder horizontal abduction at 90° and 150° of elevation have been demonstrated to be useful in increasing pectoralis minor flexibility and the ER and posterior tilt of the scapula during forward elevation.(7)
Shoulder horizontal abduction stretching at 90° (a) and 150° (b
Scapular stabilization exercises, based on stretching and strengthening, aim to improve muscle strength and joint position sense. The serratus anterior and trapezius muscles act as scapular stabilizers. The serratus anterior plays an essential role in determining scapular ER and posterior tilt, and the lower trapezius helps to stabilize the scapular position. Scapular stabilization exercises are based on closed and open kinetic chain exercises, including push-ups on a stable or unstable surface, lawnmower exercises and resisted scapular retraction.(7)
Representation of push up exercises (a), lawnmower exercises (b), and resisted scapular retraction
Push-ups on a stable surface improve the serratus anterior stretch . The same exercise, performed on an unstable surface, increases the activation of the trapezius, while decreasing the activation of the serratus anterior. The upper and lower trapezius muscles can be better stimulated with upward rotation shrugs [139]. Specific shrug exercises may be beneficial to increase the upward rotation angle and the upper trapezius activity in subjects with SD and the corresponding scapular downward rotation syndrome (7)
Researches
Abnormal scapular movement patterns in young, athletically active adults can be visually recognized and distinguished from normal patterns with satisfactory reliability by trained athletic trainers and physical therapists using the SDT.(8)
Scapular dyskinesis was found to have a greater reported prevalence (61%) in overhead athletes compared with non-overhead athletes (33%).(3)
Studies demonstrated the occurrence of SD in elite young swimmers, with an incidence of 8.5% on a cohort of 661 asymptomatic elite athletes(9)
A randomized trial showed that exercises for SD with electrical stimulation, performed at 120° of shoulder abduction, improve the distance between the spine and scapula(10)
Kinesio taping over the upper and lower trapezius muscles may rebalance the scapular muscles, increasing the upward scapular rotation(7)
Altered scapular kinematics could be linked to pain in the region of the neck(11)
At Valley Healing Hands, we provide the best Physical Therapy treatment for Shoulder dyskinesia or Scapular dyskinesia. We provide a perfect atmosphere for our patients with a one on one ratio for the best quality of care needed for maximum outcomes and return to daily routine. Our physical therapist are highly qualified and will plan an individualized treatment routine, customized to your specific needs. Our patients are highly satisfied with our services. You can learn about what they have to say about us here and get connected to us here. Our patients love us and you too will !!!
We also recommended to you the following video for a detailed understanding of scapular dyskinesia :https://www.youtube.com/watch?v=dk2DkybMJ38
Sources
(5) https://pubmed.ncbi.nlm.nih.gov/33211975/#
(8) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2657031/
(9) Preziosi Standoli, J.; Fratalocchi, F.; Candela, V.; Preziosi Standoli, T.; Giannicola, G.; Bonifazi, M.; Gumina, S. Scapular Dyskinesis in Young, Asymptomatic Elite Swimmers. Orthop. J. Sports Med. 2018, 6, 2325967117750814.
(10) Walker, D.L.; Hickey, C.J.; Tregoning, M.B. The Effect Of Electrical Stimulation Versus Sham Cueing on Scapular Position During Exercise in Patients with Scapular Dyskinesis. Int. J. Sports Phys. Ther. 2017, 12, 425–436
(11) Amorim, C.S.; Gracitelli, M.E.; Marques, A.P.; Alves, V.L. Effectiveness of global postural reeducation compared to segmental exercises on function, pain, and quality of life of patients with scapular dyskinesis associated with neck pain: A preliminary clinical trial. J. Manip. Physiol. Ther. 2014, 37, 441–447.
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