Scapular Dyskinesis And It’s Treatment

What is Scapular Dyskinesis

Any bony or soft tissue injury around the shoulder can alter the roles of the scapula in motion or at rest. Scapular dyskinesis (also referred to as SICK scapula syndrome) is an alteration or deviation in the scapula’s normal resting or active position during shoulder movement.

The shoulder is a complicated and mobile joint that allows for a great range of motion. However, this mobility also makes the shoulder liable to instability-based injuries, such as subluxations or dislocations, which can damage the bones, cartilage, or ligaments.

The humeral head is a ball and socket joint that sits on the glenoid socket, like a golf ball on a tee. This is compared to the ball and socket joint of the hip, which is more like a ball sitting in a soup bowl (less range of motion, much more stable). Anatomy provides the framework for function.

Scapular Dyskinesis

The scapula, or shoulder blade, is a fascinating piece of anatomy. It is essentially a free-floating structure, attached to the thorax, or chest, by numerous muscles, and connected to the acromion, or outermost point of the shoulder, by a small bony bridge. In other words, it is the link between the arm and the torso.

The scapula can do many impressive things, such as depress, retract, protract, tilt, upwardly rotate, and downwardly rotate. Its wide range of motion makes it very important for overhead motions.

Various muscles have to work together to rotate the scapula upward to raise the humerus overhead. This coordinated effort is known as a force-coupling.

For the scapula to move upwards, the muscles of the supraspinatus, deltoid, upper trapezius, lower trapezius, and serratus anterior must work together to rotate it.

This blog post does not go into the details of this relationship, but it is important to understand that there is a lot of effort involved in reaching overhead.

When the muscles that move the shoulder blade are in good balance with each other, the shoulder blade can move through its full range of motion without any problems. However, when this muscle balance is disturbed and the shoulder blade’s motion or position becomes altered, we call this scapular dyskinesia.

It is not an injury or musculoskeletal diagnosis by itself but is related to injury or pain, or occurs as a result of changes in shoulder muscle activation, humeral position or motion, among other causes.

Quantifying scapular dyskinesia

There is a lot of debate among clinicians, especially those who work mostly with shoulders, about this.

Scapular dyskinesia is a condition characterized by abnormal movement of the shoulder blade. It is easy to see the difference between normal and abnormal overhead motion. However, we prefer to be as objective as possible in healthcare by quantifying things.

When assessing scapular dyskinesis, the key questions are: How severe is it? Is there a reliable scoring system for this? Or is it simply present or not present? And finally, does this influence the rehabilitation program we build for the patient?

The challenge in assessing scapular dyskinesia clinically comes from the fact that the scapula moves in three dimensions, and is often obscured by the soft tissue around it, making it difficult to directly measure its position.

A clinical evaluation of scapular dyskinesia should include visual observation to determine if there is scapular dyskinesis and an evaluation of nearby anatomy that could be responsible for the scapular dyskinesis.

There are several scapular dyskinesis grading scales, many of which are reliable, but most of them lack validity because there is no direct correlation between scapular dyskinesia and pain.

For example, it was difficult to find two evaluators who could both consistently and accurately rank a shoulder’s level of motion on a 4-point scale. A grading system for scapular dysfunction was created by Dr Ben Kibler. He defined 3 types of abnormal scapular motion and 1 type of normal motion. The testing scale wasn’t found to be reliable enough to be used in a clinical setting. It was difficult to find two evaluators who could both consistently and accurately rank a shoulder’s level of motion on the 4-point scale.

The grading scale he created was further refined through two additional studies and then made much easier to pass by being renamed the Scapular Dyskinesis Test (SDT) (5).

The Strength-Deficit Test (SDT) is a test used to assess scapular dyskinesia. The test is performed by having the patient lift a weight while the clinician visually observes the patient’s shoulder movement. In a subsequent study, each shoulder is given a score of either “normal,” “subtle,” or “obvious” based on the clinician’s observation.

The study found that scapular dyskinesia was present in 52% of patients with shoulder impingement syndrome. In this study, scapular dyskinesia was defined as winging or dysrhythmia. The study found that scapular dyskinesia was present in 52% of patients with shoulder impingement syndrome.

This test was more successful when looked at statistically. There was good agreement between different clinicians who rated it (75%-82%), and a moderately weighted kappa (0.48-0.61), meaning that usually, two clinicians could come to the same conclusion about a patient’s score.

The study found that those with scapular dyskinesia were not more likely to report symptoms, which relates to the validity of the study. The study may not be accurate if the assessments don’t correlate to symptoms.

The researcher, Tim Uhl, used a “yes” or “no” scale to develop a dynamic test for observing scapular dyskinesia. In a subsequent study, he looked at a symptomatic group and an asymptomatic group.

There was no difference in the prevalence of scapular dyskinesia between those with and without shoulder pain.

In 2012, a systematic review of the diagnostic accuracy of scapular physical examination tests found that scapular dyskinesis or abnormal scapular position are not good indicators of shoulder pain.

There is evidence that scapular asymmetries are common in healthy individuals, but this does not mean that scapular dyskinesia tests help diagnose shoulder pain.

Normal scapular movement vs. the SICK scapula

At the top of a horizontal movement like a push-up, your shoulder blades should be pushed forward, and as your chest moves towards the floor, your shoulder blades should move back in coordination with the movement of your shoulder joint.

Your scapulae should rise and rotate upwards as your arms move up during an overhead press, and then reverse the direction as your arms move back down.

Faults in the scapula’s movement can cause a syndrome known by the acronym SICK.

The term SICK was coined to describe the pathological scapular conditions often seen in professional baseball players. As most people know, baseball players are prone to developing shoulder problems.

SICK stands for:

S – Scapula Malposition (Poor Positioning of the Scapula)

I – Inferior Medial Border Prominence (Scapular Winging)

C – Coracoid Pain and Malposition (Anterior Scapular Pain)

K – Kinesis abnormalities are caused by an imbalance in the muscles that move the scapula. This can lead to the scapula not moving in a normal pattern. The most common kinesis abnormality is winging of the scapula. This is when the scapula sticks out at the back, away from the rib cage. The scapula is a bone in the shoulder that is moved by a group of muscles. If these muscles are not balanced, it can lead to the scapula not moving in a normal way. The most common kinesis abnormality is winging of the scapula. This is when the scapula sticks out at the back, away from the rib cage.

If your shoulder appears to droop and the medial border protrudes when the shoulder is at rest, this may be a sign of a SICK scapula.

Everyday problems caused by a SICK scapula

Athletes and non-athletes alike can have their quality of life reduced by weak muscles, as these muscles can lead to a loss of functional strength, reduced range of motion, and joint instability.

Because the shoulder is the most mobile joint in the body, it is also the least stable. Abnormal kinesis combined with poor positioning of the scapula can lead to mobility issues and eventually more serious problems like:

  • Labral Injuries 
  • Shoulder Impingements 
  • Rotator Cuff Injuries 
  • Bursitis 

You can still have these problems even if you aren’t an elite baseball player.

The following text discusses how rounded shoulders and thoracic kyphosis, common posture problems seen in office workers and cell phone addicts, can lead to scapular protrusion and other symptoms of SICK scapula syndrome.

The following text explains the importance of performing the scapular test while holding a lightweight. The test should be performed unloaded to identify any problems with the scapula.

  1. Stand with your shirt off and position a camera behind you or have a friend watch as you perform this test
  2. Hold a 5-pound dumbbell in your hands and keeping your arms straight, flex your shoulders (lift them straight up in front of you and then overhead)
  3. Look for the signs of dyskinesis mentioned above

4 techniques to cure the 3 types of Scapular Dyskinesis

You will need to perform exercises to improve mobility, stabilize your scapula, retrain proper movement patterns and strengthen the muscles surrounding the glenohumeral joint to fix your scapular dyskinesis.

(The glenohumeral joint is a ball and socket joint that includes a complex, dynamic, articulation between the glenoid of the scapula and the proximal humerus. Specifically, it is the head of the humerus that contacts the glenoid cavity (or fossa) of the scapula.)

The four techniques that the author has used in the past to help clients with SICK scapula syndrome and promote a pain-free range of control in the shoulder joint are as follows: 1. 2. 3. 4.

Scapular Dyskinesis technique no. 1: Overhead wall rollout

This is a great exercise to have the shoulder blade move when the arm moves, and also for strengthening the muscles around the shoulder blade as well as the muscles that control the stomach.

  1. Stand leaning against a wall with an ab-wheel in your hands
  2. Protract your scapulae
  3. Slowly roll the ab-wheel up the wall and ensure you’re shrugging your shoulders to elevate your scapulae as your arms rise up while keeping tension in your core to avoid lumbar extension
  4. Roll back down slowly and with control and return to the initial position.
  5. Breathe naturally throughout the movement

Scapular Dyskinesis technique no.2: Supine serratus activator

This technique will help improve your posture by resetting your shoulder blades and reactivating the muscles in your back.

  1. Lay on your back with legs bent, feet flat and arms by your side
  2. Bend your elbows so your fingers are pointing up towards the sky with palms facing together
  3. Drive your elbows into the ground to activate the lats and posterior deltoids without trying to pinch your scapulae together
  4. Picture your chest opening and the medial border of the scapulae moving up into your body and hold for 5 seconds
  5. Relax briefly and repeat

Scapular Dyskinesis Technique no. 3: Horizontal band fly

This exercise is good for opening up tight pecs and anterior delts while also training the scapulae.

  1. Stand tall with a nice natural posture
  2. Hold the ends of a strength band in each hand with the length of it passing behind your back
  3. Keeping your arms straight, open your chest and reach back as if you’re trying to touch the backs of your hands together behind you in line with your shoulders while retracting your scapulae and holding for 3 seconds
  4. Now sweep your arms around so they’re pointing straight in front of you while protracting your scapulae and hold for 3 seconds then repeat

Scapular Dyskinesis Technique no. 4: Hovering push up

The hovering push-up is a great exercise to train the shoulder blades in a retracted position, enabling shoulder extension and fixing your rounding shoulders.

  1. Lie in a prone position
  2. Place your palms on the ground with your thumbs under your armpits or a bit lower
  3. Raise both your chest and palms off the ground and hold for 10 to 30 seconds keeping your scapulae retracted and hands and fingers extended

You can treat your scapular dyskinesia and SICK scapulae by correcting your scapular movement patterns, building strength, and increasing the range of control of the shoulder joint. These techniques will also prevent these issues from returning or beginning.

Closing thoughts

While scapular dyskinesia is a common finding in abnormal shoulders, it is not the only thing solely responsible for shoulder pain.

While exercise may help lessen your shoulder pain, it will not have much effect on improving the appearance of scapular dyskinesia. Your success should be judged by how your symptoms improve, rather than how much the clinician observing your condition thinks your scapula improves with overhead movement.

There is no argument that arm care, periscapular strengthening, and rotator cuff strengthening have benefits. However, it is very important to know what goals are realistic to shoot for (symptom management) and what outcomes are generally unattainable (perfect scapular mechanics) to manage patient expectations, time, and psyche.

 

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