The shoulder is responsible for approximately 16% of all primary care musculoskeletal visits. (1) Many of these patients exhibit an often overlooked, altered scapular position and motion pattern called, “Scapular dyskinesis” (2,3). The dominant shoulder is affected more frequently (4).
Simply put, the scapula (or shoulder blade) moves with your arm. If it is moving improperly (called dyskinesis), it places undue stress on the joints of the shoulder, and can cause issues such as impingement, rotator cuff tendonitis, etc. An integrated motion between the scapula as the arm is raised provides efficient function and joint stability (5).
What causes scapular dyskinesis?
Muscular imbalance, neurologic injury, or joint pathology are potential causes of scapular dyskinesis. The most common origin of scapular dyskinesis is muscular imbalance resulting from a combination of weakness, tightness, fatigue or altered activation. (6) Tightness in the pecs or short-head of the biceps leads to dyskinesis by placing excessive pull on the coracoid process. (7) It is not completely clear whether pec minor tightness is a causative factor or an adaptive response to scapular malposition. (8) Weakness or fatigue in the lower trapezius or serratus anterior triggers dyskinesis from inadequate acromial elevation. (5,9,10) Dyskinesis can occur from dysfunction in the distal kinetic chain, including hip abductor or core weakness (52). Hyperkyphosis or “slouched” postures are known contributors (11-13).
Scapular dyskinesis may be secondary and present in many other shoulder issues. Neurologic origins of scapular dyskinesis include cervical radiculopathy or peripheral neuropathy (7,15). Injury to the spinal accessory nerve, long thoracic nerve, or suprascapular nerve is the cause of scapular dyskinesis in approximately 5% of cases (16).
What are the effects of scapular dyskinesis?
Scapular dyskinesis diminishes subacromial space and leads to decreased rotator cuff strength, impingement symptoms, and eventual rotator cuff damage (17-22). One hundred percent of patients with shoulder impingement demonstrate scapular dyskinesis (3). Uncoordinated movement of the scapula and humerus leads to a loss of dynamic stability in the glenohumeral joint via excessive strain on the anterior glenohumeral ligaments, with concurrent diminished rotator cuff strength. (3,23-25) Sixty-four percent of patients with glenohumeral instability demonstrate scapular dyskinesis (3).
Although scapular dyskinesis is linked to a variety of shoulder problems, it may be asymptomatic initially. Up to 76% of healthy college athletes demonstrate some form of asymptomatic scapular asymmetry (26).
Evaluation and Assessment of Scapular Dyskinesis:
The goal of clinical evaluation is to recognize altered scapular mechanics and identify the underlying causative factors and identify the components of scapular dyskinesis, including scapular malposition, inferior angle prominence, coracoid tenderness/malposition, and dyskinesis (16). Assessment begins with observation for winging (prominence of the inferior angle or medial border of the scapular) or asymmetry (3).
Scapular dyskinesis becomes more apparent with dynamic testing, particularly during the lowering phase of arm movement. (3-28)
Range of motion deficits are possible. Posterior shoulder tightness may limit internal rotation, which leads to scapular protraction and dyskinesis- particularly in overhead athletes. Trigger points are possible in the pectoral, biceps, upper trapezius, and rotator cuff muscles. Scapular dyskinesis is often part of a larger biomechanical problem- “Upper crossed syndrome”. Clinicians should assess for even more distant origins of instability, including hip abductor weakness.
Management of Scapular Dyskinesis:
Conservative management is capable of producing significant improvements in pain and function, despite the fact that research shows static and dynamic measurements of scapular dyskinesis remain relatively unchanged after three months of care (38). The successful management of scapular dyskinesis requires identifying and addressing the causative components. Treatment should begin by restoring flexibility of tightened and hypertonic tissues. Myofascial release and stretching may be necessary for the pec minor, biceps, and upper trapezius (39-40) Strengthening exercises should be directed at the serratus anterior, lower trapezius, and middle trapezius. (41-43)
Rehabilitation for scapular dyskinesis:
Rehab of scapular dyskinesis is most effective when muscles are activated in functional patterns versus isolated strengthening. (46) Functional exercises useful for rehabbing scapular dyskinesis include: inferior glide and low row. (47) Strengthening exercises should be performed with the patient focusing on scapular retraction, thereby, increasing serratus anterior and lower trapezius activation. Patients should avoid “shrugging” their shoulders, or otherwise activating the upper trapezius. Patients demonstrating weakness in the hip abductors or core musculature may require proximal stabilization prior to implementing more specific scapular stabilization (48,49). The use of manipulative therapy is a “preferred” treatment that may accelerate recovery (50,51). Therapeutic taping may provide benefit for scapular dyskinesis patients (53,54).
At Creekside Chiropractic & Performance Center, we are highly trained to treat this condition. We are the only inter-disciplinary clinic in Sheboygan county that provides chiropractic, myofascial release, ART (Active Release Technique), massage therapy, acupuncture, physiotherapy, rehabilitative exercise, nutritional counseling, personal training, and golf performance training under one roof. Utilizing these different services, we can help patients and clients reach the best outcomes and the best versions of themselves. Voted Best Chiropractor in Sheboygan by the Sheboygan Press.
Evidence Based-Patient Centered-Outcome Focused
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