By Robert McCabe, PT, DPT, OCS
There has been a shift away from structural measurements towards movement - based assessment for the patient/client with "scapula dyskinesis" . Scapular dyskinesis is an alteration or deviation in the normal resting or active position of the scapula during shoulder movement. The acronym SICK scapula syndrome was introduced by Burkhart back in 2003 and was found to be a common contributor to shoulder pain in overhead athletes. Kibler, in 2002, proposed a classification ( type 1, 2 and 3) system that could be used to identify those with scaplula dyskinesis.
Over the past decade or so, there has been an evolution towards a movement-based assessment of the scapula. However, subsequent research has shown that asymmetry is common, whether it be at rest or with movement. For example, Matzuki found greater scapula downward rotation at rest , but greater upward rotation during end range of abduction in the dominant arm of normal subjects. Laudner found decreased upward scapula rotation in baseball players. This finding was more pronounced in pitchers vs. position players. Why would baseball athletes have decreased upward scapula rotation? The authors theorized that acquired hyperlaxity of the inferior glenohumeral ligament, as a result of repetitive throwing, would decrease tension on the scapula attachment during arm abduction.
This is a good example of form following function and may just be an adaptation to the throwing motion.
In 2017, Plummer looked at 135 participants, in which approximately half had painful shoulders and the other half had non-painful shoulders. They had two experienced clinicians determine if a shoulder demonstrated scapular dyskinesis or not. They found that there were NO significant differences in the prevalence of SICK scapula between the group with shoulder pain and the group without shoulder pain.
Most recently, the use of symptom modification tests, such as the scapula assistance test or scapula reposition tests, have been used due to the limitations in placing too much importance on symmetry. These tests are more meaningful as the goal is to determine IF ABNORMAL MOVEMENT IS CONTRIBUTING TO SHOULDER PAIN. A meta analysis supported the use of both tests ( no other tests were recommended) , however the scapula assistance is much easier to perform and takes less time.
With the scapula assistance test, you have the patient actively flex the shoulder through full range and report any pain (NPRS scale 0-10). You repeat the motion with the scapula assistance maneuver applied Essentially, you are performing a mobilization with movement (posterior tilt and upward rotation). [See Video Below]
A positive test is a reduction in shoulder pain by 2 or more points. A positive test does not tell you the specific cause (i.e. pectoralis tightness or lower trapezius weakness) which must be addressed during the rest of the evaluation. Finally, patient "buy in" is more likely if you can SHOW the patient that their scapula is part of the problem!
1. Kibler WB et al.Qualitative clinical evaluation of scapular dysfunction: a reliability study. J Shoulder Elbow Surg.2002;11:550-556. 2. McClure PW et al. Direct 3-dimentional measurement of scapular kinematics during dynamic movements in vivo.J Shoulder Elbow Surg.2001:10:269-277. 3. Laudner KG, Stanek JM, Meister K. Differences in scapular upward rotation between baseball pitchers and position players. Am J Sports Med. 2007 Dec;35(12):2091-5. 4. Muraki T et al.Lengthening of the pectoralis minor muscle during passive shoulder motions and stretching techniques: a cadaveric biomechanical study.Phys Ther.2009;89:333-341. 5. Plummer HA, Sum JC, Pozzi F, Varghese R, Michener LA. Observational Scapular Dyskinesis: Known-Groups Validity in Patients With and Without Shoulder Pain. J Orthop Sports Phys Ther. 2017 Aug;47(8):530-537 6. Rabin et al. The intertester reliability of the scapular assistance test.JOSPT.2006;36:653-660. 7. Schwartz C, Croisier JL, Rigaux E, Denoël V, Brüls O, Forthomme B. Dominance effect on scapula 3-dimensional posture and kinematics in healthy male and female populations. J Shoulder Elbow Surg. 2014 Jun;23(6):873-81. 8.Struyf F, Nijs J, Mottram S, Roussel NA, Cools AM, Meeusen R. Clinical assessment of the scapula: a review of the literature. Br J Sports Med. 2014 Jun;48(11):883-90.
Robert “Bob” McCabe, PT, DPT, OCS, has extensive experience educating fellow clinicians and is passionate about delivering relevant, up-to-date content to therapists nationwide. Dr. McCabe has treated multiple professional athletes, specializing in shoulder health. He is an adjunct instructor at New York University as well as New York Institute of Technology. Dr. McCabe is SFMA, McKenzie and Graston certified, and is an APTA Board Certified Orthopedic Clinical Specialist.