Authors: Cory Chirstensen PT, DPT
Bryan Wright PT, DPT, Cert. MDT, OCS
The Scapula (shoulder blade) serves as a stable base for rotator cuff activation and functioning. Scapular rotation is critical for proper shoulder function. Any bony or soft tissue injury around the shoulder can alter the roles of the scapula in motion or at rest and thus effect the entire mechanical chain of function in the upper extremity.
SCAPULAR DYSKINESIA DEFINED
Scapular dyskinesis (which may also be referred to as SICK scapula syndrome) is an alteration or deviation in the normal resting or active position of the scapula during shoulder movement. Abnormal repetitive motion of the scapula, though sometimes asymptomatic, can increase the chances of progressive injury.
COMMON SIGNS AND SYMPTOMS
- Pain and/or tenderness around the scapula when using the arm overhead or carrying heavy objects with the arm at the side.
- Snapping or popping sensation around the scapula with shoulder movement
- Loss of strength with shoulder and upper extremity use.
- Asymmetrical posture both statically and dynamically
- Winging or tipping of the scapula
- Instability of the shoulder
CAUSES OF SCAPULAR DYSKINESIA
Commonly, scapular winging is thought of being the result of muscle weakness or imbalance, as well as poor timing of muscular contraction. It can also develop from poor overhead mechanics and overuse or repetitive motions such as throwing or serving. While the superficial perspective enforces these concerns to be addressed, the deeper look begs to answer the question of why poor motor control of the scapula has ensued in the first place.
While muscle weakness or imbalance may play a part in scapular winging, there are often underlying neurological issues that contribute to the problem. For example, cervical radiculopathy patterns, as well as impairments to the long thoracic nerve can contribute to the overall problem of scapular winging and actually be the root of it. A thorough diagnosis will often make a major difference in treatment outcomes.
5 TREATMENT TOOLS FOR SCAPULAR DYSKINESIS
Many tools can be used with the treatment of scapular winging. Some are more effective than others when taking into account the interactions between empirical evidence, clinician expertise and patient preference. In this article, we briefly review 5 high powered tools for treating scapular winging. Each is discussed below:
- Quad rock backs
- One arm wall push backs
- Chicken wings
- Pattern assistance exercises
The use of NMES has been substantially supported in rehabilitative literature. NMES use is backed up by research articles regarding the effectiveness of it to improve volitional force production (VFP) of the rotator cuff. There has been significant evidence showing muscular fiber recruitment occurs in other segments of the body, and it holds true for the shoulder girdle as well.
The use of NMES should not be done as a passive modality, rather as an assistance to movement in order to have some facilitation of the muscle contraction during movement. Placement of NMES onto the serratus anterior will not only allow us to have better assistance for scapular movement and placement onto the thoracic wall, but this may also help those that are having neurological deficits of the long thoracic nerve as well in reinforcing that neuromuscular connection.
2) Quad Rock Backs:
This is aimed at assisting muscular contraction in a low level closed chain exercise. To perform a quad rock back, the patient is placed into a quadruped position with equal weight bearing though all the extremities. The patient is then instructed to protract the shoulders, push through the arms into the ground, and then to push themselves back onto their feet with maintaining pressure through their arms. The combined motions of shoulder protection and then pushing through the arms will allow for an assistance movement of upward rotation of the scapula during shoulder elevation.
Quad rock backs combined with the use of NMES is very effective in assisting with the treatment of scapular winging. The key to this therapeutic exercise (therex) is to establish a good understanding of the movement pattern and implement frequent repetition of this movement. The more reps the individual is able to facilitate this movement, the better. Having the patient perform 30, 40, even 50 reps of this during the day would certainly help in the appropriate re-education of the this movement pattern.
3) One arm wall push backs:
This therex is a progression to quad rock backs. Again, this is not a therapeutic exercise that is passive. The purpose of this exercise is to bridge the gap between being in a quadruped position and open chain shoulder elevation movements.
The patient is brought to the wall, with the involved UE placed onto the wall. The patient is then to protract the scapula and PUSH themselves back onto their feet with the UE, returning back to the starting position. Good control of the scapula with the protraction and upward rotation is essential before progressing to an open chain activity where there will be a higher demand of the scapula during movement.
4) Chicken Wings:
Chicken wings are indicated when the patient has been able to establish good upward rotation of the scapula and is progressing with endurance training of the musculature. There are 3 different phases of this exercise. Good control and endurance is foundational in each phase in order to progress into the other phases.
The patient is placed in a prone position with their hands placed of the back of their heads and then passively placed into a position of upward rotation of the scapula. The patient is then instructed to elevate their UEs off of the ground and hold that position for a given amount of time, with the amount of time increasing as they are able to tolerate.
The progression to this exercise is to simply increase the lever arm of the exercise. This is done by having the patient straighten out their UEs to around 100 degrees of abduction. They then lift the UEs back into the air and hold for the instructed amount of time.
This phase of the exercise is done with the UEs fully straightened out while still in the prone lying position. The patient is then instructed to lift both UEs off of the ground while making a “Y” shape and holding that position for a given amount of time. Making sure that the patient is not compensating with over activation of the upper traps will be key to ensuring that this exercise is done correctly and that you are getting the desired movement of the scapula and endurance of the surrounding musculature.
5) Pattern Assistance:
Quoting Mike Reinold, pattern assistance is: “anything you do for the antagonist, or an antagonistic movement pattern, is going to be a pattern assistance for the agonist, or the correct movement pattern that you are looking for”. An example of how pattern assistance can be used in the clinic would be the performance of a single arm pull down.
With the patient is performing an exercise that requires scapular depression to complete the movement, the patient would then allow the band/weight of the exercise to then pull the arm back up into shoulder elevation and scapular upward rotation. The use of the this tool could be parallel to a Muscle Energy Technique (MET) movement of the scapula. MET is where the patient is contracting the lat, and neighboring antagonistic muscles, then allowing them to relax. This assists the movement of the scapula into upward rotation during the unloading phase. Ensuring that the patient is appropriate for this type of movement is key, to disallow for compensation of movement to sneak into this intervention.
The treatment of scapular winging has many components to it and is not a simple prescription strategy. It requires an understanding of the kinetic chain, diagnostics, an understanding of biomechanics and advanced prescription skill sets. However; with the use of the these tips, along the with a proper screening of any neurological component to the problem, we will have a better chance at producing better outcomes for our patients.
Call us at 208-736-2574 with questions regarding SICK scapula, or email email@example.com with collaboration. We look forward to serving those with scapular dyskinesia and getting them back to their game.