The document discusses scapular dyskinesis, a condition characterized by abnormal scapular motion affecting shoulder function, which can lead to pain and increased risk of injuries. It covers the anatomy of the scapula, biomechanics of shoulder movement, etiology, diagnosis methods, and management strategies including both conservative and surgical approaches. Emphasis is placed on the importance of rehabilitation in restoring optimal scapular motion to prevent further injuries.

1. SCAPULAR DYSKINESIS
Presenter- Dr Binod Chaudhary
Moderator- Assoc. Prof. Dr Jhapindra Pokharel
HOD, Department of Orthopaedics
WRH, PoAHS

2. Contents
• Backgrounds
• Biomechanics
• Definition
• Etiology
• Diagnosis
• Management

3. Background
Scapula
• Large triangular bone located just lateral to
the vertebral column and posterior part of
the thoracic wall.
• Parts: body, neck, glenoid and coracoid
process
• Borders: medial, superior and inferior
• Surface: anterior and posterior
(supraspinatus and infraspinatus)

4. Scapulothoracic joint
• Interval between the scapula and underlying wall
of ribs
• Not a true joint
• Separated by thin layer of loose areolar tissue to
glide freely in all directions
• Any movement of the scapula on the thorax
results in movement of either the
acromioclavicular joint, the sternoclavicular joint
or both

5. Biomechanics
Resting position of scapula
• Anteriorly 10-20 degrees
• Internally rotated 30-45 degrees
• Upward tilt 3 degrees
4 biomechanical roles
• Center of rotation of humerus
• Anchor of humerus onto the thoracic wall
• Keeps acromion from obstructing movement
of humerus both into abduction and in flexion
• It is the means by which forces are
transmitted from core to the arm

6. Motion
• Primary motion: Elevation and Depression
Movement up and down along the rib cage
• Secondary motion:
Protraction and retraction
Upward and downward rotation
Internal and external rotation
Anterior and posterior tipping

7. Shoulder abduction
• The first 30-60 degrees of arm abduction
occur at glenohumeral joint, scapula
remaining fixed(setting phase)
• Further shoulder abduction the ratio of
glenohumeral motion to scapulothoracic
motion occurs at 2:1
• i.e for every 300
of abduction, 200
occurs at
glenohumeral and 100
occurs at scapula-
thoracic joint

8. • 17 different muscles attach to or originate
from scapula providing stability and
movement
• Muscles controlling glenohumeral joint
motion
Forward elevation: deltoid(anterior part), pectoralis major,
biceps, coracobrachialis
Abduction: deltoid(middle part), supraspinatus
External rotation: infraspinatus, teres minor, deltoid(posterior
part)’
Internal rotation: subscapularis, pectoralis major, latissimus
dorsi, deltoid
Adduction: pectoralis major, latissimus dorsi, teres major,
teres minor
Extension: deltoid(posterior part), latissimus dorsi, teres major

9. • Muscles controlling scapulothoracic
motion
Elevation: upper part of trapezius, rhomboids
Retraction: upper part of trapezius, rhomboids
Protraction: serratus anterior
Upward rotation: upper part of trapezius,
serratus anterior
Downward rotation: lower part of trapezius,
rhomboids

10. Scapular dyskinesis
• A condition characterized by abnormal scapular
motion and/or position.
• Collectively called ‘scapular winging’, ‘scapular
dyskinesia’ and more appropriately ‘scapular
dyskinesis’
• Kibler and Sciascia, 2010
1. Abnormal static or dynamic scapular motion
characterized by Medial Border Prominence
2. Inferior angle prominence and/or early scapular
elevation or shrugging on arm elevation
3. Rapid downward rotation during arm lowering

11. • May refer to
Abnormal static position- including
prominence of its medial border or inferior
angle
Abnormal scapular movement- including early
scapula elevation on arm elevation or rapid
downward scapular rotation during arm
descend
Scapular dyskinesis

12. • Scapulothoracic kinematics plays a key role in normal function of
upper extremity
• When rhythm is altered, there is changes in
Glenohumeral angulation
AC joint strain
Size of subacromial space
Activation of rotator cuff muscles
Loss of normal arm position and motion

13. Pathoanatomy
Altered Joint Mechanics
Scapular dyskinesis affects the normal movement patterns of the shoulder joint,
leading to altered joint mechanics and increased stress on surrounding structures.
Reduced Range of Motion
The abnormal scapular movement can limit the overall range of motion of the
shoulder, restricting activities like reaching, lifting, and overhead movements.
Increased Risk of Injury
The altered mechanics and increased stress can increase the risk of developing
injuries like rotator cuff tears, labral tears, and other shoulder problems.
Pain and Discomfort
Scapular dyskinesis can cause pain and discomfort in the shoulder, neck, and upper
back, making it difficult to engage in daily activities.

14. Etiology
Commonest causative mechanisms of dyskinesis have a soft tissue
components, involving either intrinsic muscle pathology, inflexibility or
inhibition of normal muscle activation

15. Etiology
• Primary, secondary or voluntary
Primary
• Due to abnormalities arising in the scapula-thoracic
articulation, periscapular muscles and nerves.
1. Neurological dysfunction: intrinsic or extrinsic nerve
lesion
2. Osseous: osteochondroma of scapula/ribs, fractures,
thoracic spine (scoliosis/kyphosis)
3. Soft tissues: congenital absence of muscles(SA, trapezius,
rhomboids), muscle avulsion, scapulothoracic bursitis

16. Secondary
• Arises as a response to abnormalities in the shoulder
1. Shoulder pain- reflex spasm of periscapular muscles
2. Glenohumeral stiffness- abnormal scapular motion in an attempt to
maintain overall motion
3. Deltoid fibrosis(congenital, secondary to intramuscular injections)
Voluntary
• Psychological issues

17. Risk factors
• Sports involving overhead activities
• Increase in throwing velocity
• Loose joint
• Previous or repeat shoulder injuries
• Poor physical condition (strength and
flexibility)
• Thoracic kyphosis/scoliosis
Postacchini R, Carbone S. Scapular dyskinesis Diagnosis and
treatment.OA Musculoskeletal Medicine 2013 Oct 18;1(2):20

18. SICK Scapula
• S: Scapular Malposition on rib cage
• I: Inferior Medial Scapular Winging
• C: Coracoid Tenderness
• K: Scapular DysKinesis
Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology Part III: The SICK
scapula, scapular dyskinesis, the kinetic chain, and rehabilitation. Arthroscopy. 2003 Jul 1;19(6):641-61.

19. Types
• Type I: inferomedial scapular border prominence
• Type II: Medial border prominence
• Type III: Superomedial border prominence
• Type IV: normal scapular position and motion
Postacchini R, Carbone S. Scapular dyskinesis: diagnosis and treatment. OA Musculoskeletal Medicine. 2013 Oct
18;1(2):20.

20. Diagnosis Clinical Presentation
Symptom Description
Pain Aching, burning, or sharp pain in the
shoulder, neck, or upper back.
Weakness Difficulty lifting or reaching, especially
overhead, due to muscle weakness.
Scapular Winging Visible protrusion of the scapula from
the back, particularly during arm
movements.
Limited Range of Motion Restricted ability to move the shoulder
through its full range of motion.
Clicking or Popping Auditory sensations during shoulder
movements, indicating abnormal joint

21. Physical examination
• Assessment done in 3 stages
First stage: Assessment with arm at rest
Second stage: evaluation done while asking the subject to elevate
and then lower the arm in the sagittal and/or scapular plane
Third stage: observe the scapular motion while elevating and
lowering arm with some 2-3 kg weight in one hand and then in other
hand

22. • Bony prominences
• Stability of SC and AC joints
• Clavicle examination
• Coracoid position / tenderness
• Muscle bulk and symmetry
• Rule out presence of cervical pathology
• Assessment of vertebral curvature
• Patterns of Dyskinesis(Winging)
Physical examination

23. Winging
• Static (pseudo- winging) vs Dynamic (true winging)
• Medial vs lateral winging

24. • Clinical assessment is done by two methods
Four type method (4 types of dyskinesis)
Two type method (Yes/No)
Yes- indicates presence of one or more dyskinetic patterns
No- indicates a normal motion
• A 3D kinematic analysis by electromagnetic tracking can be also
performed to determine presence of dyskinesis and to establish
validity of two methods
Physical examination

25. Physical examination
Special tests
• Scapular assistance test(SAT)
• Scapular Retraction test (SRT)
• Lateral Scapular slide test

26. • Lennie test
• Scapular load test
• Rotator cuff integrity, labral stability and internal impingement should
be shought as they may represent the underlying cause of dyskinesis
• Glenohumeral stability test

27. Investigations
1)X-ray:- Complete shoulder series.
-usually unremarkable finding.
-can help identify clavicle or AC joint injury.
2)Nerve conduction study:- Long thoracic nerve , dorsal scapular nerve
or spinal accessory nerve.
3)Electromyography:- identify injury & the potential for recovery in
periscapular muscles.

28. • MRI :- Delineate muscle injury.
- identify inflammation or lesion that suggest
an alteration of
the scapular kinematics.
- MR arthrograms can identify associated
labral pathology.
• CT-Scan :- investigation of scapular position & soft
tissue to assess the
cause of symptoms.

29. Management
• Aim: To restore the scapular position and dynamics
• Goal: improve the kinematic chain at different levels from cervical and
thoracic spine to the shoulder
• Depend on underlying causes and clinical symptoms
Secondary to a shoulder pathology - address primary shoulder
disorder
Primary scapular dyskinesis -address scapula

30. • Both conservative and surgical
• Conservative:
Leave alone
Analgesia
Steroid injections of bursae in scapulo-
thoracic bursitis
Kinesio taping(KT)
Physiotherapy
Management

32. Physiotherapy
• Maintain glenohumeral motion
• Stretch stiff muscles
• Improve posture
• Strengthen weak or compensatory muscles
• Correct muscle dis-coordination

33. Physiotherapy
Open book stretch Cross body adduction stretch
Corner stretch Low row
Sleeper stretch

34. Physiotherapy
Inferior glide
Robbery exercise
Lawnmower exercise

35. Physiotherapy
Fencing Rhythmic stabilization
Scapular clock

36. Physiotherapy
Wall wash
Punches in multiple planes
Shoulder dump

38. Surgical
• Scapulothoracic compression test
• Nerve surgery
Neurolysis
Nerve grafting
Muscle transfer – to improve pain and function and
reduce winging

39. Serratus anterior palsy
Conservative treatment : 6-18 months
Scapular brace
Post trauma – poor prognosis

40. Operative
Nerve issues:
• Neurolysis of the long thoracic nerve – signs of nerve compression
• Supraclavicular decompression as the nerve traverses the scalene
• Nerve transfer – lateral branch of thoracodorsal nerve to the long
thoracic nerve
• Muscle avulsion – early repair of serratus anterior avulsion

41. Techniques
• Dynamic muscle transfer – split pectoralis
major
• Static stabilization uses fascial graft or sliing
• Scapulothoracic fusion – salvage operation,
FSHD

42. Trapezius palsy
• Less response to conservative
• Physical therapy, neck and core strengthening, transcutaneous nerve
stimulation, external support, analgesics

43. Surgery
• Neurolysis
• End-to-end suturing
• Nerve grafting

44. Eden-Lange muscle transfer
• Dynamic muscle transfer - transfer of levator scapulae
to the acromion and the rhomboid muscles to the
infraspinous fossa

45. Rhomboid palsy
• Majority conservatively
• Strengthening of the trapezius is the primary objective of physical
therapy

46. Surgery
• Neurolysis or decompression
• Repair of detached muscles
• Fascial sling operation

47. Osseous procedure
• Osteochondroma – resection
• Malunions of scapular fractures – osteotomy
• Scapulothoracic fusiobn – aims to improve pain but at the expense of
arm motion

48. Principles of management
• Management is focused on rehabilitation
• Asymptomatic subjects who occasionally play overhead sports:
if dyskinesis is mild: no need treatment
if clear cut alteration: rehabilitation
• Athletes ‘at risk’ must be treated before becoming symptomatic

49. • Symptomatic overhead athletes should initially avoid activitis
involving affected shoulder and start rehabilitation
• Return to sport at low level may be allowed when significant
improvement in tissue stretching is obtained
• Full return to competitive sports can be permitted after complete
resolution of scapulothoracic alterations, but rehabilitation should be
pursued at least for 4 to 6 months.

50. Rehabilitation Programs
• Aim :- Restore scapular muscular control & balance (scapular retraction ,
posterior tilt and ER).
• Serratus anterior & trapezius muscles act as scapular stabilizers.
• Objective :- is to balance the ratio between the three parts of trapezius,
that is UT/LT & UT/MT and activate serratus anterior.
• Rehabilitation is based on a proximal to distal regain of motion, control , &
strength

51. Take home message
• SD is not a diagnosis or an injury, instead it is an impairment of optimal
scapular motion and can be a risk factor for shoulder and elbow injuries
• History- primary, secondary or Voluntary
• Etiology – LTN palsy(traction), SAN (iatrogenic)
• Examine from back
• Medial or lateral winging(Trapezius or Rhomboid)
• Key muscles tested – S anterior, Trapezius, Rhomboid
• Majority improves non surgical 18 mths
• Scapular compression test – surgical intervention

52. References
• Azar FM, Canale ST, Beaty JH. Campbell's Operative Orthopaedics, E-Book. Elsevier Health Sciences;
2021
• Warwick D, Blom A, Whitehouse M. Apley and Solomon’s System of Orthopaedics and Trauma. CRC
Press; 2021 Dec 6.
• Miller MD, Thompson SR. DeLee & Drez's Orthopaedic Sports Medicine E-Book: 2-Volume Set.
Elsevier Health Sciences; 2018 Dec 20.
• Charalambous CP. The shoulder made easy. Springer; 2019 Feb 27.
• Kibler WB, Sciascia AD. Disorders of the Scapula and their role in shoulder injury. Gewerbestrasse,
Switzerland: Springer International Publishing. 2017:128-30.
• Kibler WB, Sciascia A. Current concepts: scapular dyskinesis. British journal of sports medicine. 2010
Apr 1;44(5):300-5.
• Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology Part III:
The SICK scapula, scapular dyskinesis, the kinetic chain, and rehabilitation. Arthroscopy. 2003 Jul
1;19(6):641-61.

53. Thank you