aaos scapular dyskinesis

Journal of the American Academy of Orthopaedic Surgeons142

The understanding of shoulderfunction in throwing or work activi-ties and of shoulder dysfunctionafter injuries has focused on (1)describing how the humerus movesin relation to the glenoid, (2) howthe glenohumeral ligaments andlabrum statically constrain humeraltranslation, and (3) how the rotatorcuff dynamically constrains gleno-humeral motion. The entire scapula,not just the glenoid, is intimatelyinvolved in all of these functions,but its specific involvement is un-deremphasized, especially as adynamic contributor to shoulder/arm function and dysfunction.Alterations in scapular position andmotion occur in 68% to 100% ofpatients with shoulder injuries.1

Specific information about the roleof the scapula can help the clinicianunderstand and treat shoulderinjuries. Knowledge of scapularkinematics, function, and evaluationis growing, and understanding the

role of the scapula in shoulder func-tion and dysfunction is evolving.Both basic research and clinicalstudies have served to define nor-mal shoulder function, scapulardyskinesis, methods of classifica-tion, evaluation techniques, andrehabilitation methods.

Normal Scapular Function

The scapula is anatomically and bio-mechanically intimately involvedwith shoulder function. During theprocess of shoulder and arm move-ment to achieve a change in gleno-humeral position as well as duringmotions required for athletic anddaily activities, the two are linked.The scapula, shoulder, and arm areeither stabilized in or move to cer-tain positions to generate, absorb,and transfer forces that accomplishwork or athletic tasks. Alterationsof scapular position at rest, or with

coupled arm motion, are commonlyassociated with injuries that createclinical dysfunction of the shoulder.These alterations, which may be theresult of injury or may exacerbatean existing injury (and thus mayincrease symptoms), are calledscapular dyskinesis,1 a general termdescribing the loss of control ofscapular motion and position seenclinically. The term does not sug-gest etiology or define patterns thatcorrelate with specific shoulderinjuries. Classification of scapulardyskinesis patterns and positionscan help to determine treatment.

A primary role of the scapula isthat it is integral to the glenohumeralarticulation, which kinematically is aball-and-socket configuration. Tomaintain this configuration, thescapula must move in coordinationwith the moving humerus so that theinstant center of rotation, the mathe-matical point within the humeralhead that is the axis of rotation of theglenohumeral joint, is constrainedwithin a physiologic pattern through-out the full range of shoulder mo-

Dr. Kibler is Medical Director, LexingtonSports Medicine Center, Lexington, KY. Mr.McMullen is Manager, Sports Medicine andPhysical Therapy, Lexington Sports MedicineCenter.

Reprint requests: Dr. Kibler, 1221 South.Broadway, Lexington, KY 40504.

Copyright 2003 by the American Academy ofOrthopaedic Surgeons.

Abstract

Scapular dyskinesis is an alteration in the normal position or motion of thescapula during coupled scapulohumeral movements. It occurs in a large num-ber of injuries involving the shoulder joint and often is caused by injuries thatresult in the inhibition or disorganization of activation patterns in scapular sta-bilizing muscles. It may increase the functional deficit associated with shoulderinjury by altering the normal scapular role during coupled scapulohumeralmotions. Scapular dyskinesis appears to be a nonspecific response to shoulderdysfunction because no specific pattern of dyskinesis is associated with a specificshoulder diagnosis. It should be suspected in patients with shoulder injury andcan be identified and classified by specific physical examination. Treatment ofscapular dyskinesis is directed at managing underlying causes and restoringnormal scapular muscle activation patterns by kinetic chain–based rehabilita-tion protocols.

J Am Acad Orthop Surg 2003;11:142-151

Scapular Dyskinesis and Its Relation to Shoulder Pain

W. Ben Kibler, MD, and John McMullen, ATC

Scott J Sevinsky MSPT











Vol 11, No 2, March/April 2003 143

tion.2,3 Proper alignment of the gle-noid allows optimum function ofboth the bony constraints and themuscles of the rotator cuff, allowingconcentric glenohumeral motion.4,5

The second role of the scapula isto provide motion along the tho-racic wall. The scapula retracts(externally rotates) to facilitate theposition of cocking.6 This cockingposition is important in the baseballthrow, the tennis serve, and theswimming recovery. As accelera-tion proceeds, the scapula must pro-tract laterally (internally rotate) in asmooth fashion, then anteriorlyaround the thoracic cage, to main-tain a normal position in relation tothe humerus and to dissipate someof the deceleration forces that occurin follow-through as the arm goesforward.4,6,7 In workers, scapularretraction creates a stable base forthe abducted or elevated arm to dotasks that require reaching, pushing,or pulling.

The first two roles (glenohumeralarticulation and motion along thethoracic wall) confer a coupled inter-dependency between movements ofthe arm and scapula that createsdynamic stability for the gleno-humeral joint in the positions andmotions of athletic or work activi-ties.3,7 This dynamic relationship hasbeen compared to a ball on a seal’snose. (The seal’s nose must move tokeep the ball from falling off.)

The third role that the scapulaplays in shoulder function is eleva-tion of the acromion, which occursduring the cocking and accelerationphases of throwing or arm eleva-tion, to clear the acromion from themoving rotator cuff to decrease im-pingement and coracoacromial archcompression.8,9 Although rotatorcuff fatigue may cause superiorhumeral head migration to triggersubacromial impingement in thisposition,10 lower trapezius and ser-ratus anterior muscle fatigue alsomay contribute to impingement bydecreasing acromial elevation.11

The final role that the scapulaplays in shoulder function is as a linkin proximal-to-distal sequencing ofvelocity, energy, and forces of shoul-der function.10,12,13 For most activi-ties, sequencing begins at the ground,and individual body segments (links)are coordinated by muscle activationand body position to generate, sum-mate, and transfer force throughthese segments to the terminal link.This sequence is termed the kineticchain.10,12,14 These serial muscle acti-vation patterns stabilize the scapulaand increase the control of its motionand position as the arm is moved.The scapula is thus pivotal in trans-ferring large forces and high energyfrom the legs, back, and trunk to thedelivery point, the arm and thehand,12-15 thereby allowing moreforce to be generated in activitiessuch as throwing than could be doneby the arm musculature alone. Thescapula, serving as a link, also stabi-lizes the arm to more effectivelyabsorb loads that may be generatedthrough the long lever of the extend-ed or elevated arm.7

Scapular Dyskinesis

Scapular dyskinesis1 is defined asobservable alterations in the posi-tion of the scapula and the patternsof scapular motion in relation to thethoracic cage. Several factors maycreate these abnormal patterns andpositions.

Bony Posture or InjuryA resting posture of excessive

thoracic kyphosis and increased cer-vical lordosis can result in excessivescapular protraction and acromialdepression in all phases of athleticactivity, increasing the potential forimpingement.6,8 Fractures of theclavicle can shorten or angulate thestrut, which helps maintain properscapular position. Acromiocla-vicular joint injuries, instabilities, orarthrosis also interfere with clavicu-

lar strut function and can alterscapular kinematics by not allowingthe normal progression of the in-stant center of scapular rotationfrom the medial scapular border tothe acromioclavicular joint.3,16

Alteration in Muscle FunctionScapular dyskinesis most fre-

quently occurs as a result of alter-ation of muscle activation or coordi-nation. The motion of the scapularesults from patterned muscle acti-vation and passive positioningresulting from trunk and arm accel-eration. The muscle activation pat-terns result in force couples forscapular control5,7,17,18 (Fig. 1).Scapular stabilization requires cou-pling of the upper and lower trape-zius and rhomboid muscles with theserratus anterior muscle. Scapularelevation involves the serratus ante-rior and lower trapezius musclescoupled with the upper trapeziusand rhomboid muscles.17 Lowertrapezius activation is especiallyimportant in maintaining the normalpath of the instant center of scapularmotion in arm elevation. This resultsfrom the mechanical advantage ofits attachment at the medial aspectof the scapular spine and to itsstraight line of pull as the arm ele-vates and the scapula rotates.18

Most nonphysiologic motion andthus abnormal mechanics that occurwith the scapula can be traced toalterations in the function of themuscles that control it.11,18-21 Injuryto the long thoracic nerve can altermuscular function of the serratusanterior muscle, and injury to thespinal accessory nerve can alterfunction of the trapezius muscle,causing abnormal stabilization andcontrol, which occurs in approxi-mately 5% of cases.

More commonly, the scapular sta-bilizing muscles (1) are directlyinjured from direct-blow trauma; (2)have microtrauma-induced strain inthe muscles, leading to muscle weak-ness; (3) become fatigued from repet-

































































itive tensile use; or (4) are inhibitedby painful conditions around theshoulder. Muscle inhibition orweakness is quite common in gleno-humeral pathology, whether frominstability, labral pathology, orarthrosis.10,11,19,21 The serratus anteri-or and the lower trapezius musclesare the most susceptible to the effectof the inhibition, and they are morefrequently involved in early phasesof shoulder pathology.4,6,11 Muscleinhibition and resulting scapulardyskinesis appear to be a nonspecificresponse to a painful condition in the

shoulder rather than a specific re-sponse to a certain glenohumeralpathology. This fact is supported bythe finding of scapular dyskinesis inas many as 68% of patients with rota-tor cuff abnormalities, 94% withlabral tears, and 100% with gleno-humeral instability problems.1,22,23

Inhibition is seen as a decreased abil-ity of the muscles to exert torque andstabilize the scapula as well as disor-ganization of the normal muscle fir-ing patterns of the muscles aroundthe shoulder.4,11,21 The exact natureof this inhibition is not clear. The

nonspecific response and the disor-ganization of motor patterns suggesta proprioceptively based mecha-nism. Pain, either from direct orindirect muscle injury, and fatigue oruncontrolled muscle strain, havebeen shown to alter proprioceptiveinput from Golgi tendon organs andmuscle spindles.

Contractures and OtherFlexibility Problems

Inflexibility or contracture of themuscles and ligaments around theshoulder can affect the position and

Upper trapezius Upper trapezius

Middle trapezius

Middle trapezius

Deltoid

Deltoid

20.8° 14.2°81.8°

Lower trapeziusLower trapezius

Lower serratus anterior Lower serratus anterior

⊕

Upper trapezius

Middle trapezius

Deltoid

139.1°

47.7°54.2°Lower trapezius Lower serratus anterior

⊕

Upper trapezius

Middle trapezius

Deltoid

>168.1°

Lower trapezius Lower serratus anterior

⊕

⊕

Figure 1 Force couples for scapular rotation. In early coupled arm elevation/scapular rotation (A and B), the upper and lower trapeziusand serratus anterior muscles have long moment arms and are effective rotators and stabilizers. With higher arm elevation (C), the uppertrapezius moment arm is shorter, while the lower trapezius and serratus anterior moment arms remain long and continue to rotate thescapula. With maximum arm elevation (D), the lower trapezius is ideally placed to maintain scapular position and pull along its longaxis. As a result of these activities, the scapular instant center of rotation (⊕) moves from the medial border of the spine to the acromiocla-vicular joint. (Adapted with permission from Bagg SD, Forrest WJ: A biomechanical analysis of scapular rotation during arm abductionin the scapular plane. Am J Phys Med Rehabil 1988;67:238-245.)

A B

C D










motion of the scapula. Tightness inthe pectoralis minor or in the shorthead of the biceps, both of whichattach to the coracoid process, cancreate an anterior tilt and forwardpull on the scapula. Lack of fullinternal rotation of the glenohumer-al joint, caused by capsular or mus-cular tightness, affects the normalmotion of the scapulothoracic artic-ulation.6,23-25 This creates a “windup” effect so that the glenoid andscapula are pulled in a forward infe-rior direction by the moving rotat-ing arm.6 This can create an exces-sive amount of protraction of thescapula on the thorax as the armcontinues into an adducted positionin follow-through during throwingor into forward arm elevation inworking. Because of the ellipsoidgeometry of the upper portion of thethorax, the scapula moves dispropor-tionately anteriorly and inferiorlyaround the thorax with more scapu-lar protraction.9,26

Classification of ScapularDyskinesis

Three-dimensional biomechanicalanalysis of possible scapular mo-tions shows that the scapula movesaround three axes of motion simul-taneously.6,11 Patterns of abnormal

motion in scapular dyskinesis arebest observed by first determiningthe position of the scapula with thepatient’s arms at rest at the side,then by observing the scapularmotion as the arms are elevated andlowered in the scapular plane.These dyskinetic patterns fall intothree categories, which correspondto the three planes of motion on theellipsoid thorax.27 This system canhelp identify the type of abnormalscapular motion and thus the re-habilitation required by musclestrengthening and restoration offlexibility. Type I (Fig. 2, A) is char-acterized by prominence of the infe-rior medial scapular border. Thismotion is primarily abnormal rota-tion around a transverse axis. Type

II (Fig. 2, B) is characterized byprominence of the entire medialscapular border and representsabnormal rotation around a verticalaxis. Type III (Fig. 3) is character-ized by superior translation of theentire scapula and prominence ofthe superior medial scapular bor-der. The net effect of the scapulardyskinetic patterns is an adverseeffect on the normal role of thescapula in shoulder function.28

Effects of ScapularDyskinesis

Loss of Retraction/ProtractionControl

Lack of full scapular retractioncauses loss of the stable cockingpoint in throwing or loss of the sta-ble base in arm elevation.3 Lack offull scapular protraction around thethoracic wall increases the decelera-tion forces in the shoulder joint5,29

and causes changes in the normalsafe zone relationship between theglenoid and humerus as the armmoves through the accelerationphase.3,4,7 Too much protraction be-cause of tightness in either the jointcapsule or the anterior coracoidmuscles will cause impingement asthe scapula rotates down and for-ward.8,9,16,17,24,25

Loss of protraction control alsocreates functional anteversion of

A B

Figure 3 A, Type III dyskinesis, with prominence of the superior medial border (leftscapula). B, Scapular superior translation on the thorax.

Figure 2 A, Type I dyskinesis, with inferior medial border prominence (left scapula). B, Type II dyskinesis, with prominence of the entire medial border (left scapula).

A B




























the glenoid, decreasing the normalbony buttress to anterior translation.This may increase the shear stresseson the rest of the anterior stabilizingstructures—the labrum and gleno-humeral ligaments—thus increasingthe risk of shear injury or strain.30

Posteriorly, this anteversion increas-es the degree of impingementbetween the posterior superior gle-noid and posterior rotator cuff23 bymoving the posterior aspect of theglenoid closer to the externallyrotated and horizontally abductedarm.

Loss of Elevation ControlLoss of ability to elevate the acro-

mion can be a secondary source ofimpingement in other shoulder prob-lems, such as glenohumeral instabil-ity.9,21,23,31 The serratus anterior andespecially the lower trapezius ap-pear to be the first muscles involvedin inhibition-based muscle dysfunc-tion.4,11 Lack of acromial elevationand consequent secondary impinge-ment can be seen early in manyshoulder problems, such as rotatorcuff tendinitis and glenohumeralinstability. This can play a role in the development of further symp-toms.9,10,22

Loss of Kinetic Chain FunctionOne of the most important ab-

normalities in scapular biomechan-ics is the loss of the link function inthe kinetic chain. If scapular motionis impaired, the forces generatedfrom the lower extremity and trunkwill not be effectively transmitted tothe upper extremity.

Evaluation

Scapular evaluation should includedistant contributions to normalscapular function and dyskinesis.Similarly, dynamic evaluation ofmotion, muscular activation, andcorrective maneuvers should bedone.

Leg and trunk muscle activity isimportant12,15,29 in shoulder andarm throwing, serving, and liftingactivities and as a major source offacilitation of scapular muscle acti-vation.26 Lumbar lordosis, pelvictilt, and hip rotational abnormalitiesshould be checked.

Thoracic and cervical postureshould be evaluated because in-creased thoracic kyphosis or scolio-sis may have a direct effect on themotion of the scapula by creating anabnormal surface contour for scapu-lar motion. Excessive cervical lordo-sis may indicate posterior cervicalmuscle or fascia tightness or anteriorclavicular fascia tightness, which canaffect scapular retraction and pro-traction.

The evaluation of the scapulaitself should be done mainly fromthe posterior aspect (Figs. 4-6).Scapular position may be evaluatedin several ways. Abnormalities ofwinging, elevation, or rotation mayfirst be examined in the resting posi-

tion. In long-standing scapulardyskinesis, resting winging may beseen. Pure serratus anterior muscleweakness resulting from nerve palsywill create a prominent superiormedial border and depressed acro-mion, whereas pure trapezius mus-cle weakness resulting from nervepalsy will create a protracted inferi-or border and elevated acromion.20

There may be pain to palpationover the anterior shoulder at thecoracoid tip, secondary to adaptivetightness and scar in the pectoralisminor muscle and the short head ofthe biceps. In addition, the superioror entire medial border may bepainful to palpation or with motionbecause of similar tightness or scarin the levator scapulae or lowertrapezius insertions, or both. Finally,there may be trigger points, areas oftenderness in the body of the uppertrapezius muscle.

Motion and position should beexamined in both the elevating andlowering phases of motion. Muscle

A B

Figure 4 Scapular assistance test. The examiner assists serratus anterior and lowertrapezius muscle activity as the arm is elevated. Relief of impingement symptoms is a pos-itive test. A, Examiner’s right hand position at start of test. B, Assisted scapular rotationwith arm elevation.
















































weakness and mild scapular dyski-nesis are more common in the lower-ing phase of arm movement. Thesecommonly present as a hitch or ajump in the otherwise smooth mo-tion of the scapula or scapular bor-der and may be more noticeable withseveral repetitions of the motion.

An effective maneuver for evalu-ating scapular muscle strength is anisometric pinch of the scapulas inretraction. Scapular muscle weak-ness may manifest as a burning painin less than 15 seconds, whereas thescapula normally may be held inthis position for 15 to 20 secondswithout burning pain or muscleweakness. Wall push-ups are effec-tive for evaluating serratus anteriormuscle strength. Abnormalities ofscapular winging may be notedwith 5 to 10 wall push-ups.

The scapular assistance test (Fig. 4)evaluates scapular and acromial involvement in subacromial impinge-ment. In a patient with impinge-ment symptoms with forward ele-

vation or abduction, assistance forscapular elevation is provided bymanually stabilizing the scapulaand rotating the inferior border ofthe scapula as the arm moves. Thisprocedure simulates the force-coupleactivity of the serratus anterior andlower trapezius muscles. Elimina-tion or modification of the impinge-ment symptoms indicates that thesemuscles should be a major focus inrehabilitation.

The scapular retraction test (Fig. 5)involves manually stabilizing thescapula in a retracted position onthe thorax. This position confers astable base of origin for the rotatorcuff and often will improve testedrotator cuff strength. (That is, theapparent strength generated by iso-lated rotator cuff strength testingoften improves by retesting in thescapula-retracted position.) Thescapular retraction test also fre-quently demonstrates scapular andglenoid involvement in internal im-pingement lesions.26 The positiveposterior labral findings on modi-fied Jobe relocation testing will bedecreased with scapular retractionand removal of the glenoid from theexcessively protracted impingementposition.

Quantitative measurement ofscapular stabilizer strength can be

achieved by the lateral scapular slidetest.28 This semidynamic test evalu-ates three positions of the scapula oninjured and noninjured sides in rela-tion to a fixed point on the spine asvarying amounts of loads are put onthe supporting musculature. Thesepositions offer a graded challenge tothe functioning of the shoulder mus-cles to stabilize the scapula. The firstposition is with the arms relaxed atthe sides (Fig. 6, A). In this position,the inferior-medial angle of thescapula is palpated and marked onboth the injured and noninjuredsides. The reference point on thespine is the nearest spinous process,which is marked with an X. Themeasurements from the referencepoint on the spine to the medial bor-der of the scapula are measured onboth sides. The second position iswith the hands on the hips, the fin-gers anterior and the thumb poste-rior with approximately 10° ofshoulder extension. The new posi-tion of the inferomedial border ofthe scapula is marked, and the refer-ence point on the spine is main-tained. The distances once again arecalculated on both sides. The sameprotocol is done for the third posi-tion, with the arms at or below 90°of arm elevation with maximal inter-nal rotation at the glenohumeral

Figure 5 Scapular retraction test. Theexaminer stabilizes the medial scapularborder as the arm is elevated or externallyrotated. Relief of impingement symptomsis a positive test.

A B

Figure 6 Lateral scapular slide. A, Position 1: arms at rest at sides. B, Position 3: armsabducted at or below 90° with maximal internal rotation.




















































joint (Fig. 6, B). This final positionpresents a challenge to the musclesin the position of most commonfunction at 90° of shoulder elevation.A 1.5-cm asymmetry is the thresholdfor abnormality and is most com-monly seen in position 3. The lateralscapular slide test is more sensitivefor dyskinetic patterns that occurwith excessive protraction or otherscapular movement away from thespine (types I and II).

Examination of other structurespertinent to the scapular evaluationincludes assessment of arthrosis orinstability of the acromioclavicularjoint, shortening of the clavicle(from fracture or distal clavicleresection), and glenohumeral rota-tion and muscle strength.

Treatment of ScapularDyskinesis

Most of the abnormalities in scapu-lar motion or position can be treatedby physical therapy to relieve thesymptoms associated with inflexibil-ity or trigger points and to reestab-lish muscle strength and activationpatterns.20,28,32 Surgical treatment isused to repair the source of the un-derlying abnormalities and often isan integral part of the treatment pro-gram.

Bony abnormalities such as mal-union of a clavicular fracture or anacromioclavicular joint separationmay be the cause of the dyskinesis.More commonly, the source of mus-cle inhibition or imbalance is gleno-humeral internal derangement, suchas instability, labral tears, rotatorcuff injury, or tendinitis. Whenstructural problems or the internalderangement has been corrected,scapular muscle rehabilitation maybe initiated.

RehabilitationOnce the complete and accurate

diagnosis of all factors causing orcontributing to scapular and shoul-

der problems is established, scapularrehabilitation can be initiated.19,26,33

Scapular rehabilitation is a compo-nent of comprehensive shoulder re-habilitation. Rehabilitation shouldstart at the base of the kineticchain,33 which usually means cor-recting any strength or flexibilitydeficits in the low back and thoraciclevels before starting on the scapular

component. This phase includesexercises for flexibility, strengthen-ing the trunk, and correction of pos-tural abnormalities.

Range of motion of the gleno-humeral joint can be improved byappropriate stretching emphasizingthe posterior capsule rather thanstretching the entire upper limb.Scapular retraction and massage

Table 1Guidelines for Integrated Rehabilitation of Scapular Dyskinesis

Exercises Weeks (estimate)

Scapular MotionThoracic posture 1-3Trunk flexion/extension/rotation 1-3Lower abdominal/hip extensor 1-5

Muscular FlexibilityMassage 1, 2Modalities (eg, ultrasound, electronic stimulation) 1-3Stretching (eg, active-assisted, passive, PNF) 1-8Corner stretches (pectoralis minor) 1-3Towel roll stretches (pectoralis minor) 1-3Levator scapulae stretches 1-3“Sleeper” position stretches (shoulder external rotators) 1-3

Closed Kinetic Chain Cocontraction ExercisesWeight-shifting 1, 2Balance board 1, 2Scapular clock 1, 2Rhythmic ball stabilization 2Weight-bearing isometric extension 1, 2Wall push-up 2Table push-up 3-5Modified to prone push-up 5-8

Axially Loaded AROM ExerciseScaption slide 2-5Flexion slide 2-5Abduction glide 3-5Diagonal slides 2-6

Integrated Open Kinetic Chain ExercisesScapular motion exercises plus arm elevation 3-8Unilateral/bilateral tubing pulls with trunk motion 4-8Modified lawn mower series 3-6Dumbbell punches with stride

(progressive height and resistance) 6-8Lunge series with dumbbell reaches 5-8

Plyometric Sport-Specific ExercisesMedicine ball toss and catch 6-10Reciprocal tubing plyometrics 6-10

AROM = active range of motion, PNF = proprioceptive neuromuscular facilitation



can increase the tightness of thecoracoid-based muscles.

Rehabilitation ProtocolRehabilitation of scapular dyski-

nesis (Table 1) is based on a proxi-mal-to-distal protocol26,33 (Figs. 7-10). It emphasizes achieving fulland appropriate scapular motionand coordinating that motion withcomplementary trunk and hipmovements. Once scapular motionis normalized, these movement pat-terns serve as the framework forexercises to strengthen the scapularmusculature. Function, rather thantime, determines a patient’s progressthrough this protocol. In the earlyrehabilitation phases, hip and trunkmotions are the foundation neces-sary to achieve appropriate scapularmotion. As scapular control increas-es, scapular exercises may progressby decreasing the emphasis on prox-imal facilitation.

This protocol may be seen as aflow of exercises that progress as thepatient achieves more proximal con-trol and advances toward integra-tion of the scapular exercises withshoulder and arm exercises. Out-come studies using this rehabilita-

tion protocol have not been reportedbut are in progress. Our clinicalexperience has shown that achieve-ment of scapular control decreasesrotator cuff soreness and improvesrotator cuff function, especially earlyin rehabilitation.

Rehabilitation Phases

Acute Phase (Usually 0 to 3 Weeks)(1) Initially, avoid painful arm

movements and positions and es-tablish scapular motion by proximalfacilitation.

(2) Begin soft-tissue mobilizationand assisted stretching if muscularinflexibility is limiting motion. Ofparticular importance are the pec-toralis minor, levator scapulae,upper trapezius, latissimus dorsi,infraspinatus, and teres minor mus-cles. Active, active-assisted, passive,and proprioceptive neuromuscularfacilitation stretching techniques areeffective in restoring muscle flexibil-

ity as well as the range of motion ofglenohumeral joints.

(3) Begin upper extremity weightshifting, wobble board exercises,scapular clock exercises, rhythmicball stabilization, and weight-bear-ing isometric extension to promotesafe cocontractions. Use theseclosed kinetic chain exercises(CKC),34 in which the hand is sup-ported or has weight applied to it, invarious planes and levels of eleva-tion if the scapular positioning isappropriate. These may be startedat low levels of abduction and exter-nal rotation, then may progress to90° abduction as tolerated.

(4) Initiate scapular motion exer-cises without arm elevation. Usetrunk flexion and trunk medial rota-tion to facilitate scapular protrac-tion. Use active trunk extension, lateral trunk rotation, and hip exten-sion to facilitate scapular retraction.

(5) Include arm motion withscapular motion exercises as the

A B

Figure 8 Wall slides. A, Starting position. B, Hip/trunk extension facilitating arm motionalong smooth surface.

Figure 7 Closed-kinetic chain exercises.The body may be moved in relation to thefixed arm to determine a safe and non-painful plane of motion to start exercises.The arm may be placed on a ball to relieveexcessive eccentric loads on the weak mus-cles.



scapular motion improves. Initially,keep the arm close to the body tominimize the intrinsic load. Anexcellent early scapular stabilizationexercise is the “low row,” which in-cludes trunk/hip extension, scapu-lar retraction, and arm extension.

Recovery Phase (3 to 8 Weeks)Proximal stability and muscular

activation are imperative for appro-priate scapular motion and strength-ening. Strengthening is dependenton motion, and motion is dependenton posture.

(1) Initiate greater loads withCKC exercises such as wall push-

ups, table push-ups, and modifiedprone push-ups. Also, increase thelevel of elevation of CKC exercisesas scapular control improves. Posi-tion the patient for CKC exercisesby placing the hand, then movingthe body relative to the fixed handto define the plane and degree ofelevation (Fig. 7).

(2) Add arm elevation and rota-tion patterns to scapular motionexercises, as tolerated. If intrinsicloads are too great with the intro-duction of active elevation, use axi-ally loaded active range-of-motionexercises as a transition to openkinetic chain exercises,34 in which

the hand is freely movable. Wallslides are an example of transitionexercises (Fig. 8).

(3) Begin kinetic chain tubingexercises using hip and trunk exten-sion with scapular retraction, andhip and trunk flexion with scapularprotraction (Fig. 9). Varying anglesof pull and planes of motion areused to reproduce appropriate scap-ular functions.

(4) Use lunges with dumbbellreaches to emphasize kinetic chaintiming and coordination. Vary thelevel of arm elevation, amount ofexternal rotation, and degree ofelbow flexion in the standing orreturn position to increase the func-tional demand on the scapular mus-cles. Avoid scapular compensationssuch as winging or shrugging.

Maintenance Phase (6 to 10 Weeks)(1) When there is good scapular

control and motion throughout therange of shoulder elevation, initiateplyometric (dynamic stretch-short-ening) exercises, such as medicineball toss and catch and tubing plyo-metrics.

(2) Overhead dumbbell pressesand dumbbell punches (Fig. 10), invarious planes are advanced exercis-es requiring good scapular controlthrough a full and loaded gleno-humeral range of motion.

A B

C D

Figure 9 Kinetic chain tubing exercises, incorporating the trunk and scapula in variousplanes. A, Arm forward flexion. B, Ipsilateral hip/trunk extension with scapular retrac-tion. C, Arm abduction. D, Contralateral hip/trunk extension with scapular retraction.

Figure 10 Dumbbell punches may bedone in any safe plane.



Summary

The scapula is coupled with the arm innormal shoulder function. Alterationsin scapular motion and position are

frequently associated with shoulderinjury and dysfunction. Recognitionand evaluation of scapular dyskinesiscan lead to a comprehensive frame-work for treating and rehabilitating the

entire shoulder joint. Rehabilitationexercises are structured in a proximal-to-distal protocol that advancestoward integrating scapular exerciseswith shoulder and arm exercises.

References

1. Warner JJ, Micheli LJ, Arslanian LE,Kennedy J, Kennedy R: Scapulotho-racic motion in normal shoulders andshoulders with glenohumeral instabili-ty and impingement syndrome: Astudy using Moire topographic analy-sis. Clin Orthop 1992;285:191-199.

2. Doukas WC, Speer KP: Anatomy,pathophysiology, and biomechanics ofshoulder instability. Op Tech SportsMed 2000;8:179-187.

3. Poppen NK, Walker PS: Normal andabnormal motion of the shoulder. J Bone Joint Surg Am 1976;58:195-201.

4. Pink MM, Perry J: Biomechanics ofthe shoulder, in Jobe FW, Pink MM,Glousman RE, Kvitne RS, Zemel NP(eds): Operative Techniques in UpperExtremity Sports Injuries. St. Louis, MO:Mosby-Year Book, 1996, pp 109-123.

5. Nieminen H, Niemi J, Takala EP,Viikari-Juntura E: Load-sharing pat-terns in the shoulder during isometricflexion tasks. J Biomech 1995;28:555-566.

6. McClure PW, Michener LA, SennettBJ, Karduna AR: Direct 3-dimensionalmeasurement of scapular kinematicsduring dynamic movements in vivo. J Shoulder Elbow Surg 2001;10:269-277.

7. Happee R, Van der Helm FC: Thecontrol of shoulder muscles duringgoal directed movements: An inversedynamic analysis. J Biomech 1995;28:1179-1191.

8. Ludewig PM, Cook TM: Alterationsin shoulder kinematics and associatedmuscle activity in people with symp-toms of shoulder impingement. PhysTher 2000;80:276-291.

9. Lukasiewicz AC, McClure P, MichenerL, Pratt N, Sennett B: Comparison of3-dimensional scapular position andorientation between subjects withand without shoulder impingement.J Orthop Sports Phys Ther 1999;29:574-586.

10. Fleisig GS, Barrentine SW, EscamillaRF, Andrews JR: Biomechanics of over-hand throwing with implications forinjuries. Sports Med 1996;21:421-437.

11. McQuade KJ, Dawson J, Smidt GL:Scapulothoracic muscle fatigue associ-

ated with alterations in scapulo-humeral rhythm kinematics duringmaximum resistive shoulder elevation. J Orthop Sports Phys Ther 1998;28:74-80.

12. Kibler WB: Biomechanical analysis ofthe shoulder during tennis activities.Clin Sports Med 1995;14:79-85.

13. Kennedy K: Rehabilitation of theunstable shoulder. Op Tech Sports Med1993;1:311-324.

14. Elliott BC, Marshall R, Noffal G:Contributions of upper limb segmentrotations during the power serve intennis. J Appl Biomech 1995;11:433-442.

15. Kraemer WJ, Triplett NT, Fry AC: Anin-depth sports medicine profile ofwomen college tennis players. J SportsRehabil 1995;4:79-88.

16. Bagg SD, Forrest WJ: A biomechanicalanalysis of scapular rotation duringarm abduction in the scapular plane.Am J Phys Med Rehabil 1988;67:238-245.

17. Speer KP, Garrett WE Jr: Muscularcontrol of motion and stability aboutthe pectoral girdle, in Matsen FA III, FuFH, Hawkins RJ (eds): The Shoulder: ABalance of Mobility and Stability. Rose-mont, IL: American Academy of Ortho-paedic Surgeons, 1993, pp 159-172.

18. Bagg SD, Forrest WJ: Electromyo-graphic study of the scapular rotatorsduring arm abduction in the scapularplane. Am J Phys Med 1986;65:111-124.

19. Moseley JB Jr, Jobe FW, Pink M, Perry J,Tibone J: EMG analysis of the scapularmuscles during a shoulder rehabilita-tion program. Am J Sports Med 1992;20:128-134.

20. Kuhn JE, Plancher KD, Hawkins RJ:Scapular winging. J Am Acad OrthopSurg 1995;3:319-325.

21. Glousman R, Jobe F, Tibone J, MoynesD, Antonelli D, Perry J: Dynamic elec-tromyographic analysis of the throwingshoulder with glenohumeral instability.J Bone Joint Surg Am 1988;70:220-226.

22. Paletta GA Jr, Warner JJ, Warren RF,Deutsch A, Altchek DW: Shoulderkinematics with two-plane x-ray eval-uation in patients with anterior insta-bility or rotator cuff tearing. J ShoulderElbow Surg 1997;6:516-527.

23. Burkhart SS, Morgan CD, Kibler WB:Shoulder injuries in overhead athletes:The “dead arm” revisited. Clin SportsMed 2000;19:125-158.

24. Harryman DT II, Sidles JA, Clark JM,McQuade KJ, Gibb TD, Matsen FA III:Translation of the humeral head on theglenoid with passive glenohumeral mo-tion. J Bone Joint Surg Am 1990;72:1334-1343.

25. Tyler TF, Nicholas SJ, Roy T, GleimGW: Quantification of posterior cap-sule tightness and motion loss in pa-tients with shoulder impingement.Am J Sports Med 2000;28:668-673.

26. Kibler WB, McMullen J, Uhl T: Shoul-der rehabilitation strategies, guidelines,and practices. Op Tech Sports Med 2000;8:258-267.

27. Kibler WB, Uhl TL, Maddux JW,Brooks PV, Zeller B, McMullen J:Qualitative clinical evaluation of scapu-lar dysfunction: A reliability study. JShoulder Elbow Surg 2002;11:550-556.

28. Kibler WB: The role of the scapula inathletic shoulder function. Am J SportsMed 1998;26:325-337.

29. Young JL, Herring SA, Press JM, et al:The influence of the spine on the shoul-der in the throwing athlete. J BackMusculoskel Rehab 1996;7:5-17.

30. Weiser WM, Lee TQ, McMaster WC,McMahon PJ: Effects of simulatedscapular protraction on anterior gleno-humeral stability. Am J Sports Med1999;27:801-805.

31. Jobe FW, Kvitne RS, Giangarra CE:Shoulder pain in the overhand or throw-ing athlete: The relationship of anteriorinstability and rotator cuff impinge-ment. Orthop Rev 1989;18:963-975.

32. Kibler WB: Evaluation and diagnosis ofscapulothoracic problems in the athlete.Sports Medicine and Arthroscopic Review2000;8:192-202.

33. McMullen J, Uhl TL: A kinetic chainapproach for shoulder rehabilitation.Journal of Athletic Training 2000;35:329-337.

34. Kibler WB, Livingston B: Closed-chainrehabilitation for upper and lowerextremities. J Am Acad Orthop Surg2001;9:412-421.

aaos scapular dyskinesis

Documents