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1
MOVEMENT DYSFUNCTIONS
OF THE SCAPULA
Shantel Phillips, PT, DPT, OCS
Movement Science Fellow
Certified Movement Links Specialist
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2 Objectives
• 1. Examine scapular movement assessment exam
• Posture, functional activity, movement tests
• 2. Identify specific scapular movement syndrome
diagnoses
• 3. Create focused treatments to effectively and efficiently
address problems associated with scapular dyskinesis
• 4. Employ movement re-education and manual
correction of scapular dyskinesis
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3 Scapular Dyskinesis
• Dys: “Alteration of”
• Kinesis: “Movement”
• Generic and collective term referring to dysfunctional scapular movement patterns
• Burn et al (2016) did a systematic review
on prevalence of scapular dyskinesis
in athletes
• Overhead athletes had a greater
prevalence (61%) of scapular dyskinesis
vs nonoverhead athletes (33%)
• Hickey et al 2017 systematic review shows
that scapular dyskinesis increases the risk of
future shoulder pain by 43% in asymptomatic athletes
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4 ICF Classification
10/15/2020
Godges and Irrgang JOSPT 2008Skulpan Asavasopon Kaiser Permanente Orthopaedic PT Residency
MobilityMuscle
Power
Movement
Coordination
STIFFNESS
Osteoarthritis
Adhesive capsulitis
WEAKNESS
Rotator cuff tear
Achilles tendonitis
Lumbar muscle strain
MOTOR CONTROL
Postural dysfunction
Ligament sprains
???
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5 Movement System Impairments
• Shirley Sahrmann, PT, PhD, FAPTA
• Washington University of St. Louis
• Developed a movement exam and
diagnosis categories
• Movement diagnoses are named for
the direction of fault
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6 Movement Pioneers
• Shirley Sahrmann, PT, PhD, FAPTA
• Vladimir Janda, MD
• Pavel Kolar, PT, Paed. Dr, PhD
• Clare Frank, PT, DPT, OCS, FAAOMPT
10/15/2020 Footer
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7 Scapular Movement Exam
• Static posture
• Scapular alignment
• Muscle tone
• Dynamic movement
• Overhead forward reaching
• Scapular abduction
• Quadruped
• Upper quarter muscle length tests
• Manual strength testing
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8
Scapular Static Posture
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9 Postural Assessment
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10 Postural Assessment
Head tilt
Cervical rotationEar more visible
Shoulder slope
Muscle tone
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11 Postural Assessment
Head tilt
Cervical rotationEar more visible
Shoulder slope
Muscle tone
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12 Postural Assessment
Head tilt
Cervical rotationEar more visible
Shoulder slope
Muscle tone
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13 Postural Assessment
Head tilt
Cervical rotationEar more visible
Shoulder slope
Muscle tone
Olecranon process
Facing posteriorly Arm windows
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14 Postural Assessment
Abduction
3 inches
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15 Postural Assessment
Medial Border
Vertical or
Slight Upward
Rotation
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16 Postural Assessment
T2
T3
T7
Superior angle
Spine of
scapula
Inferior angle
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17
Scapular Dynamic Reaching
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18 Forward Reaching
Scapular Elevation
Acromion to reach C7
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19 Forward Reaching
Scapular
Upward Rotation
60 degrees
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20 Forward Reaching
Scapular Abduction
½ inch
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21 Forward Reaching
Scapular Upward Rotation
60 degrees
Inferior angle will reach
mid-axillary region
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22 Scapular Movement Syndrome Diagnoses
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23 Scapular Movement Syndrome Diagnoses
Scapular Winging
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24 Scapular Movement Syndrome Diagnoses
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25 Scapular Movement Syndrome Diagnoses
Downward
Rotation
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26 Scapular Movement Syndrome Diagnoses
Abduction
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27 Scapular Movement Syndrome Diagnoses
Depression
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28 Scapular Movement Syndrome Diagnoses
Anterior Tilt
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29 Scapular Movement Syndromes
SYNDROME INSUFFICIENT
Internal rotation (winging) External rotation
Downward rotation Upward Rotation
Abduction Adduction
Depression Elevation
Anterior tilt Posterior tilt
Sahrmann 2002
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30 Scapular Movement SyndromesSYNDROME STRONG WEAK
Downward rotation RhomboidsSerratus anterior
Lower trapezius
Upper trapezius
Anterior tilt Pectoralis minor Lower trapezius
Internal rotation
(winging)
Posterior rotator
cuff
Serratus anterior
Middle & lower
trapezius
AbductionTeres major
Serratus AnteriorMiddle trapezius
DepressionLatissimus dorsi
Pectoralis minorUpper trapezius
Sahrmann 2002; Page et al. 2012
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31 Scapular Internal Rotation
(Winging) Syndrome
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32 Scapular Internal Rotation Syndrome (Winging)
• AKA: Insufficient scapular
external rotation
• Aggravating factors:
Reaching overhead
• Population:
• Swimmers
• Weight lifters
• Kayakers
• Cross-country skiers
Sahrmann 2002
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33 Scapular Internal Rotation Syndrome (Winging)
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34 Scapular Winging
Visible
Medial BorderFlat
Thoracic Spine
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35
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36
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37 Scapular winging
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38 Scapular Winging
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39 Winging correction
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40 Winging correction
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41 Winging correction
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42 Scapular Winging - STRONG
Posterior
capsule
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43 Scapular Winging - WEAK
Serratus Anterior
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44 Scapular Winging - WEAK
Middle
trapezius /
rhomboids
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45 Scapular Winging Treatment
Quadruped rockback
Supine serratus punch
Wall push up plus
Wall upper cuts
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46 Scapular Downward Rotation Syndrome
This Photo by Unknown Author is licensed under CC BY-SA
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47 Scapular Downward Rotation Syndrome
• AKA: Insufficient scapular
upward rotation
• Population:
• Weight lifters
• Computer keyboard operators
• String instrument musicians
• Mothers of newborns
• Job requiring overhead
reaching
Sahrmann 2002
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48 Postural Assessment - NORMAL
Medial Border
Vertical or
Slight Upward
Rotation
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49 Scapular Downward Rotation
Medial
border
not
vertical
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50 Scapular Downward Rotation Syndrome
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51 Scapular Downward Rotation Syndrome
Less than
60 degrees
upward rotation
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52 Scapular Downward Rotation Syndrome
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53 Scapular Downward Rotation
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54 Hand contact
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55 Upward Rotation Assistance
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56 Downward rotation correction• Assists in scapular upward rotation and posterior tilt with
arm elevation
• Positive: relief of painful arc symptoms
Kibler and Sciascia 2010
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57 Scapular Downward Rotation - STRONG
Rhomboids
Pectoralis
minor
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58 Pectoralis minor
1 inch >1 inch
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59 Scapular Downward Rotation - WEAK
Serratus Anterior
Lower
trapezius
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60 Scapular Downward Rotation Treatment
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61
Scapular Abduction Syndrome
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62 Scapular Abduction Syndrome
• AKA: Insufficient scapular
retraction
• Aggravating factors: Pain
with reaching forward and
overhead
• Population:
• Weight lifters
• Cellist
• Hairdressers
• Swimmers
Sahrmann 2002
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63 Scapular Abduction Syndrome
• AKA: Insufficient scapular
retraction
• Aggravating factors: Pain
with reaching forward and
overhead
• Population:
• Weight lifters
• Cellist
• Hairdressers
• Swimmers
Sahrmann 2002; http://im.rediff.com/sports/2016/aug/10phelps2.jpg
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64 Scapular Abduction - NORMAL
Scapular Abduction
½ inch
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65 Scapular Abduction Syndrome
Scapular abduction
>1/2 inch
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66 Scapular abduction correction
• Grades supraspinatus and
muscle length
• Evaluates dynamic labral shear
• Clinician places scapula in
retracted position
• Positive: supraspinatus strength
is increased or the symptoms or
internal impingement is relieved
Kibler and Sciascia 2010
PAIN!
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67 Scapular abduction correction
Kibler and Sciascia 2010
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68 Scapular abduction correction
With increased assistance With manual facilitation
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69 Scapular Abduction Syndrome - STRONG
Wilk, Reinold, Andrews 2009
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70 Teres major muscle length
• Supine
• Assess scapular
abduction from thorax
• Normal is ½ inch
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71 Scapular Abduction Syndrome - WEAK
• Middle
trapezius /
rhomboids
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72 Scapular Abduction Treatment
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73 Scapular Depression Syndrome
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74 Scapular Depression Syndrome
• AKA: Insufficient scapular elevation
• May reports of pain along upper trapezius and/or headaches
• Population:• Weight lifters
• Ballet dancers
• Gymnasts
• Computer keyboard operators
• String instrument musicians
• Mothers of newborns
• Job requiring overhead reaching
Sahrmann 2002
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75 Scapular Depression Syndrome
• AKA: Insufficient scapular elevation
• May reports of pain along upper trapezius and/or headaches
• Population:• Weight lifters
• Ballet dancers
• Gymnasts
• Computer keyboard operators
• String instrument musicians
• Mothers of newborns
• Job requiring overhead reaching
Sahrmann 2002; https://i.pinimg.com/736x/59/02/75/59027525a76b8604d4358b8d23cf8c12--black-dancers-ballet-dancers.jpg
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76 Scapular Depression Syndrome
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77 Postural Assessment - Normal
T2
T3
T7
Superior angle
Spine of
scapula
Inferior angle
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78 Scapular Depression Syndrome
T 2
T 7
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79 Scapular Depression Syndrome
Scapular elevation
Acromion lower than C7
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80 Scapular Depression Syndrome
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81 Scapular Depression Syndrome – Normal vs Abnormal
Insufficient elevation
Acromion reaches C7
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82 Elevation correction
Sahrmann 2002
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83 Elevation correction
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84 Scapular Depression - STRONG
Latissimus dorsiPectoralis minor
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85 Latissimus dorsi muscle length
• Supine hooklying
• Bilateral shoulder flexion
• Normal: maintain neutral
spine
• Abnormal:
thoracolumbar extension
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86 Scapular Depression - WEAK
Upper trapezius
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87 Wall slide with shrug
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88 Scapular depression treatment
Upper trapezius unloading
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89
Scapular Anterior Tilt Syndrome
This Photo by Unknown Author is licensed under CC BY-SA
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90 Scapular Anterior Tilt Syndrome
• AKA: Insufficient
scapular posterior tilt
• Aggravating factors:
Reaching overhead
• Population:
• Swimmers
• Weight lifters
• Kayakers
• Cross-country skiers
Sahrmann 2002
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91 Scapular Anterior TiltRight cervical rotation
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92 Scapular Anterior TiltRight cervical rotation
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93 Scapular Anterior Tilt
Anterior tilt
>10 degrees
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94 Scapular Anterior TiltRight cervical rotation
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95 Scapular Anterior TiltRight cervical rotation
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96 Scapular Anterior Tilt Video
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97 Scapular Anterior Tilt
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98 Scapular Anterior Tilt
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99 Hand contact
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100 Posterior tilt correction
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101 Posterior tilt correction
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102 Posterior tilt correction
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103 Anterior Tilt - STRONG
Pectoralis minor
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104 Anterior Tilt - WEAK
Lower Trapezius
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105 Lower trapezius facilitation
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106 Lower trapezius facilitation
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107 Scapular Anterior Tilt Treatment
CORRECT
Lower trapezius activationINCORRECT
Progression: Lower trapezius activation with ER
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108 Practice - Manual Corrections
Downward Rotation
Sahrmann 2002
Winging
Abduction
Anterior Tilt
Depression
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109 Practice – Exercise Treatment
Downward Rotation
Sahrmann 2002
Winging
Abduction
Anterior Tilt
Depression
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110 Muscle Activation
• Prone
• Middle trapezius
• Lower trapezius
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111 Middle trapezius - NORMAL
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112 Middle trapezius – EXCESSIVE DEPRESSION
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113
NORMAL
EXCESSIVE
DEPRESSION
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114
NORMAL
EXCESSIVE
DEPRESSION
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Middle trapezius – EXCESSIVE ABDUCTION
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NORMAL
EXCESSIVE
ABDUCTION
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Lower Trapezius
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Lower Trapezius
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NORMAL
EXCESSIVE THORACIC
EXTENSOR ACTIVATION
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Key Points
• Scapular dyskinesis is a common broad diagnosis found especially in
overhead athletes, and there is a push to classify specific
impairments to target treatment and improve patient outcomes.
• Movement coordination deficits involve treatment targeting
normalizing motor control. Strengthening alone may be insufficient to
retrain proper movement patterns
• Allow the patient’s posture tell their story
• Assess the quality of the patient’s movement pattern
• Initiation, timing, force, and eccentric control
• Scapular diagnoses are labeled for the direction in which it will
deviate from the center. It is often opposite from the direction of
movement insufficiency.
• When facilitating proper movement pattern, remember to use broad
hand contact.
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References• Burn, M. B., Mcculloch, P. C., Lintner, D. M., Liberman, S. R., & Harris, J. D. (2016). Prevalence of Scapular Dyskinesis in Overhead
and Nonoverhead Athletes A Systematic Review, 1–8. https://doi.org/10.1177/2325967115627608
• Frank, Clare. Musculoskleetal Pain Syndromes: The Janda Approach. www.movementlinks.com
• Godges JJ, Irrgang JJ. ICF-Based practice guidelines for common musculoskeletal conditions. J Orthop Sports Phys Ther 2008; 38(4)167-168.
• Hickey, D., Solvig, V., Cavalheri, V., Harrold, M., & Mckenna, L. (2017). Scapular dyskinesis increases the risk of future shoulder pain by 43 % in asymptomatic athletes : a systematic review and meta-analysis, 1–10. https://doi.org/10.1136/bjsports-2017-097559
• Kibler, W. Ben, & Sciascia, A. (2010). Current concepts : scapular dyskinesis, (1), 300–305. https://doi.org/10.1136/bjsm.2009.058834
• Kibler, W. Ben, & Sciascia, A. (2016). The role of the scapula in preventing and treating shoulder instability. Knee Surgery, Sports Traumatology, Arthroscopy, 24(2), 390–397. https://doi.org/10.1007/s00167-015-3736-z
• Page P, Frank CC, Lardner R. Assessment and Treatment of Muscle Imbalance: The Janda Approach. Champaign: Human Kinetics, 2010.
• Mcclure, P., Tate, A. R., Pt, À., Kareha, S., Irwin, D., Zlupko, E., & Pt, I. (2009). A Clinical Method for Identifying Scapular Dyskinesis, Part 1: Reliability, 44(2), 160–164.
• Sahrmann, Shirley. Diagnosis and Treatment of Movement Impairment Syndromes. Philadelphia: Mosby, 2002.
• Tripp, B. L., & Ph, D. (2009). Evaluation of Clinical Assessment Methods for Scapular Dyskinesis. YJARS, 25(11), 1240–1248. https://doi.org/10.1016/j.arthro.2009.06.007
• Wilk EW, Reinold MW, Andrews JR. The Athlete’s Shoulder – 2nd edition. Churchill Livingstone: Philadelphia, PA. 2009.
• Viktor Kobes, Rehabilitation Prague School 1999 – 2016. Dynamic Neuromuscular Stabilization. http://www.rehabps.com/REHABILITATION/Home.html
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