Shoulder pain is very common, and there are lots of studies pointing to dysfunctional scapular movement as a cause of this, which I strongly agree with. However, it is my impression that many therapists struggle with both assessment and correction of scapular movement. Furthermore, many dogmatic teachings regarding scapular work, such as strengthening exercises as a solution for scapular dyskinesis, are confusing therapists and patients alike, as they’re proclaimed as proper correctives, yet usually fail to improve the situation.
Scapular dyskinesis is associated with many maladies. Scapular movement makes up 30% of the arm’s movement, and is naturally of critical importance when assessing and treating shoulder dysfunction. However, it may also be related to headaches (Osar, 2012), neck pain (Zakharova-Luneva et al., 2012), thoracic outlet syndrome (Swift & Nichols, 1984; Hooper et al., 2010), migraines (Saxton et al., 1999), and more. Clearly, there is potential for great gain by optimizing scapular movement, both in regards to treatment and to preventative work.
So, how should we address scapular movement? First of all, we need to understand that scapular dyskinesis is a motor control problem, not a strength problem (Osar, 2012). Therefore, strength exercises alone, such as serratus anterior training by performing scapular pushups, will rarely produce results. In my experience, such regimens will [virtually] never resolve scapular dyskinesis. And, trust me, I have definitely tried – and tried – and tried. I have not seen this approach produce results, unless there has been a mere strength deficit that’s causing the patient’s issues, i.e not a motor control problem but a true strength deficit. Unfortunately this is proving to be a rare occurrence. Scapular dyskinesis is a motor control issue, and in my experience it has to be dealt with as such.
Furthermore, many therapists and scientists today [within the pain science community] claim that scapular movement has been disproven to be of any importance, and that it should more or less be disregarded, and that biomechanical work is “outdated”. This is yet another confusing factor for many therapists, who do not know what to believe.
Be aware, though, that here is continuously emerging new studies that show the importance of scapular dyskinesis due to its correlation with pain and dysfunction. That said, I will allow you, the reader, to make up your own mind with regards to the importance of scapular movement and stability. Don’t take my word for it; try for yourself. I have.
The scapula plays a key role in nearly every aspect of normal shoulder function. Scapular dyskinesis-altered scapular positioning and motion-is found in association with most shoulder injuries. Persons with associated conditions such as shoulder impingement, rotator cuff disease, labral injury, clavicle fracture, acromioclavicular joint injury, and multidirectional instability should be evaluated for scapular dyskinesis and treated accordingly. – Kibler et al., 2012
Identification of scapular dyskinesis is a key component of the shoulder examination. Although scapular asymmetries appear to be a prevalent finding, dyskinesis in the presence of shoulder symptoms should be considered a potential factor contributing to the dysfunction. – Uhl et al., 2009
Briefly, nine of 11 studies reviewed demonstrated a statistically significant scapular movement deviation in at least 1 variable, as compared to healthy control groups. The most frequent findings have been reduced ST posterior tilting, reduced ST upward rotation, increased ST internal rotation, or increased clavicular elevation relative to the thorax – Ludewig & Braman et al,. 2011
Let us have an overview of scapular movement and anatomy first.
Scapular movement and anatomy
The scapula is connected to the thorax through both muscular and osseocartilaginous conncetions (ordinary joints). It connects to the posterior ribs through the scapulothoracic joint, which is a “muscular” joint, i.e not a real joint (such as an osseocartilaginous joint), but a functional joint. The acromial part of the scapula connects to the clavicle, which in turn connects to the sternum at the sternoclavicular joint. These are the “real” joints that connect to the scapula.
Although it is somewhat beneficial to have a deeper understanding of each of these joints’ movements and influences, it is not really necessary to correct scapular movement if proper principles are adhered to. I will however discuss them briefly when appropriate. Also, below is also an overview of the muscular anatomy, for your reference.
The scapula’s joint socket, then glenoid cavity, should follow the arm’s movement during optimal kinematics. One third, being approx. 30% of total shoulder range of motion comes from scapular movement. If the scapula moves inappropriately, loss of ROM will occur, and often so along with injuries.
The injuries occur because opposite movement between the humerus and scapula will reduce clearing between the humeral head and the coracoid (for coracoid impingement) or acromion (for subacromial “AC”-impingement), jamming the nearby structures between them, such as the supraspinatus, subscapularis or long head of the biceps.
It is paramount to learn what proper movement should, and shouldn’t look like. And, before that, one needs to know what movements the scapula performs, in order to identify them on a patient. It is of course more difficult to differentiate these movements on a patient than it is from a illustrative diagram, which is why it takes practice to get good at scapular corrective work. Let us have a thorough look at scapular movements now. I’ll speak about the most important actions first; the ones that are often reduced and dysfunctional.
I will also be talking about functional anatomy, not just textbook anatomical functions. Muscles’ functions change when structure changes. The piriformis, for example, will become an internal femoral rotator over 90 degrees of hip flexion. Likewise, the pectoralis major is a shoulder flexor when the arms are down, but a shoulder extensor when the arms are up. Muscles don’t have “one function”, they pull insertion toward origin and vice versa, and direction of pull depends on position of these.
With regards to the scapula, the teres major and external rotators will pull the inferior scapular angle toward the humerus. In practice, during shoulder elevation or abduction, it’ll pull it into upward rotation and posterior tilt. Another very relevant example, is that the anterior and middle deltoidal portions will pull the scapula into downward and/or anterior rotations if the opposing “stabilizing” muscles such as the trapezius and serratus anterior aren’t able to hold the scapula properly, i.e aren’t proper co-activating (just like the gluteus maximus would pull the pelvis into posterior tilt if the spinal extensors are inhibited).
General patterns of shoulder motion observed during humeral elevation were … glenohumeral elevation and external rotation. – Ludewig et al., 2009
Fatigue in shoulder external rotation altered the scapular resting position and the movement of posterior tilting in the early range during arm elevation in the scapular plane. – Tsai et al., 2003
Upward and posterior rotation of the scapula are often mixed up, but they are not the same. Upward rotation of the scapula involves elevation of the clavicle, adduction of the superior scapular angle and abduction of the inferior angle. This can also be called a medial rotation over a sagittal axis (imagine a rod perforating the center of the scapula, on which it may rotate).
The main muscles contributing to upward rotation are the:
- Trapezius (all three portions)
- Serratus anterior
- Ext. humeral rotators
- Teres major
Scapular upward rotation should occur during shoulder abduction, and is necessary both to increase abductile range of motion, but also to stop the acromion from jamming into the supraspinatus tendon. Inadequate upward rotation during abduction may cause supraspinatus tears, subacromial bursitis, infraspinatus tears, AC joint edemas (“bone bruise”) and so on.
Posterior scapular tilt should occur when the arm goes into flexion. Posterior tilt involves posterior rotation on the coronal axis, where the superior angle will move dorsally and the inferior angle ventrally. This allows the glenoid cavity to track the humerus’ movement during glenohumeral flexion. Posterior scapular tilt will cause the clavicle to gently elevate and retract.
Muscles contributing to posterior scapular tilt are the:
- Trapezius (middle and lower portions)
- Serratus anterior
- Ext. humeral rotators
- Teres major
- Posterior deltoid (somewhat)
Posterior scapular tilting should occur during shoulder flexion. If inadequate posterior tilt occurs as the humerus elevates forward, the humeral head may jam into the acromion, or even into the coracoid process (which is called coracoid impingement – this is especially likely if inadequate medial rotation takes place simultaneously), as I have touched upon already. The potential consequences of this are already mentioned.
Protraction & medial rotation
Protraction and medial rotation aren’t really the same thing, but because they virtually always take place simultaneously, and because it was hard to find a decent separate illustration, I’ve stuffed them together.
Protraction involves forward motion of the entire scapula, as well as the [lateral] clavicle. Medial rotation on the other hand, involves longitudinal axis internal rotation, i.e the lateral margin comes forward and the medial margin goes backward. It is technically possible to retract while medially rotating the scapula, but it is dysfunction (I’ll show an example later). Normal protractive movement should involve medial rotation as well.
The muscles that contribute to protraction and/or medial scapular rotation are the:
- Pectoralis minor
- Serratus anterior
- Ext. humeral rotators
- Teres major
Medial rotation and protraction should occur during shoulder flexion, but not so much during abduction. A 45 degree elevation of the humerus, for example, will thus involve a moderate rather than a full protractive and medial rotative movement. So, working in the sagittal plane, we need significant protraction and medial scapular rotation, as well as posterior tilt. Working in the frontal plane, the requirement for upward rotation, retraction and lateral rotation is greater.
Coracoid impingement is the main problem involved with inadequate medial rotation. The coracoid process may draw too near and jam into the bicipital tendon as well as the subscapularis, if the scapula is too externally (laterally) rotated during sagittal shoulder elevation (shoulder flexion).
Retraction & lateral rotation
On the contrary, retraction and lateral scapular rotation involves pulling the scapula as well as the clavicle backward. The clavicle may also slightly elevate. Retractive movement means to move backward, i.e scapula comes backward, with no additional movement. Lateral rotation will cause the lateral margin of the scapula to come backward and the anterior margin to come forward (if the thorax is not in the way).
The muscles that contribute to retraction and/or lateral rotation are the:
- Middle trapezius
- Lower trapezius
Retraction and lateral scapular rotation should occur when the arm goes into extension past the torso, and horizontal abduction. As far as I know, there are no “serious dangers” involved with inadequate lateral rotation. You will lose some range of motion, but there are no structures that will be seriously compromised, as with the other movements. Horizontal abduction as well as ordinary abduction of the glenohumeral joint will require increased retraction and lateral rotation.
Scapular elevation involves raising the scapula cranially. This will also cause clavicular elevation. The scapula should not elevate significantly during shoulder loading, but may elevate when reaching for something, i.e maximal range. Proper scapular height is the angulus superior in line with thoracic vertebrae T2. I’ll get more into this in the next sub-heading.
The muscles that contribute to scapular elevation are the:
- Upper and middle trapezius
- Levator scapulae
- Dare I say Omohyoid? It’s plausible.
Significant scapular elevation should not occur when the arm is loaded, because the further the scapula moves away from the thorax, the more unstable the glenohumeral foundation will become, and thus the more reduced is the potential for strength and power of the limb. However, it should occur when reaching for something, as mentioned priorly.
Scapular depression involves lowering the scapula caudally, which is downward. The clavicle will also depress during scapular depression.
Although many claim to have their “shoulders up by their ears”, the reality is that most people’s scapulas are too depressed in posture. Factually, often retracted, depressed and anteriorly tilted, giving an illusion of elevation, especially if the patient has forward head posture. This inhibits the main stabilizer of the scapula, the trapezius, and may often cause dyskinesis, brachial plexus compression syndrome, chronic headaches, and so on.
I have seen a lot of patients with very depressed scapular positioning, who sincerely believe that the shoulders are up by their ears. Perhaps weakness, imbalance and dysfunction is what they are really feeling?
The muscles that contribute to scapular depression are the:
- Serratus anterior
- Latissimus dorsi
- Lower trapezius
- Pectoralis minor
- Pectoralis major, sternal portion
Scapular depression should occur when reaching down for somehing. It should not occur [excessively] during loaded patterns.
Downward scapular rotation involves lateral rotation over a sagittal axis, where the medial border of the scapula will elevate and the lateral border simultaneously lower. Clavicular depression will also occur during scapular downward rotation.
Inappropriate downward rotation is one of the main issues in scapular dyskinesis. The patient will deactivate the trapezius and rather activate the pec minor or levator scapulae during shoulder abduction, causing the humeral head as well as the supraspinatus muscle and even subacromial bursa to jam into the acromion bone.
The muscles that contribute to scapular downward rotation are the:
- Pectoralis minor
- Levator scapulae
- Pectoralis major (if trapezius and S.A is inhibited)
- Medial deltoid (if trapezius and S.A is inhibited)
- Omohyoid? Again, plausible.
Downward scapular rotation should however occur during glenohumeral adduction, especially past the torsal midline, i.e reaching for the opposite side, like when the right arm reaches for the left foot.
In the illustration blow, to the right, we see a very inappropriate anterior tilt during shoulder flexion. Anterior scapular tilt involves coronal axis anterior rotation, meaning that the superior angle will come forward and the inferior angle will go backwards. The clavicle will depress and protract during anterior scapular tilt, reducing the space in the costoclavicular passage in which the brachial plexus is situated. In certain circumstances, this may contribute to thoracic outlet syndrome.
The muscles that contribute to anterior scapular tilt are the:
- Pectoralis minor
- Levator scapulae
- Rhomboid (vaguely)
- Pectoralis major
- Anterior deltoid (if trapezius and S.A is inhibited)
- Latissimus dorsi (if not also attached to the inferior angle, which it does in about 40% of the time according to Pouliart et al., 2005)
Anterior tilting should occur when the arm goes into extension, especially past the torso. By that I mean that it should occur as the arm passes posterior to the torso, NOT in the eccentric portion of shoulder flexion, and especially not loaded shoulder flexion.
Scapular resting position
A somewhat controversial, and very misunderstood subject is optimal scapular resting position. The scapula should rest at a longitudinal height between the T2 and T7, where the superior scapular angle is on the same height as vertebral level T2 (Sahrmann et al., 2002). It is gently anteriorly tilted to approx. 10-20 degrees (on the coronal axis), and internally rotated approximately 30 degrees (on the longitudinal axis) (Ludewig et al., 2000).
To identify scapular resting height, palpate the cervical spinous process until you find C7, which is also called the vertebrae prominens. This is because the spinous process of the C7 is much more prominent (bigger, longer) than the others, and is thus relatively easy to locate even for beginners. Once you find it, work your way down three levels, to the T2 vertebral spinous process. Once there, compare its position with the superior angle of the scapula.
It is important to remember that anterior tilting will raise the superior scapular angle. This might give an illusion of proper height, even when it is in fact depressed. Thus scapular rotation and height must all be assessed dynamically, to avoid being misled by such factors. Eventually you will be able to differentiate between right and wrong positioning without having to measure at all, but everyone needs to start somewhere.
My opinion and experience is that proper resting position is critical. Scapular resting position will dictate the general stabilizing activation pattern. In other words, if the trapezius and serratus anterior, which are very important scapular movers, aren not active during daily habits, how could we ever expect them to work optimally during loading and strenuous glenohumeral (GH) articulation? We can, of course, NOT expect such as thing!
It is an absolute myth that general strengthening for these muscles will override and “fix” poor habits and its consequences. This is absolutely not correlative with reality. To resolve poor habits, we must deal with … our habits! There are no simple shortcuts. You can’t “just train the serratus anterior and trapezius”. Did I get my point across? I hope so.
Below are two very well illustrated examples of “right and wrong”. The larger individual has a nicely situated scapular resting position. It is slighly upwardly rotated (actually, a bit too upwardly rotated, but it doesn’t really matter), and is not too low. This is a posture that continuously uses the trapezius and serratus anterior, and will act as a great foundation for optimal glenohumeral articulation and loading.
On the right, we can see severe depression, downward rotation and anterior scapular tilting in posture. This is a postural strategy that will disconnect, if you will, the posterior tilters and upward scapular rotators. The likelihood of these muscles activating properly during movement and loading is very, very slim. Furthermore, it will continuously stretch the levator scapulae and trapezius muscles, drop the clavicle down on the thoracic outlet, and promote forward occipitocervical movement as well as mid-cervical hinging. This is a common recipe for chronic headaches, disc herniations, thoracic outlet syndrome, migraines, and so on. This is also why I am VERY STRICT with posture (correct posture, not dogmatic posture) with my clients!
A slight digression: I was fortunate enough to learn the truth about resting position and scapular motor control from the biomechanical pioneer and thoughtleader, Dr. Evan Osar, and I recommend anyone to get his book “Corrective exercise solution to common hip and shoulder dysfunction“, it’s the best 15 bucks you’ll ever spend. This book is full of mythbusting facts and approaches that really work.
So, how do we correct improper scapular resting position? As I’ve mentioned, it’s not a strength problem, but a motor control problem. Proper exercises are of course beneficial and will deal with some of the symptoms, but not the cause, which is the motor dysfunction. Naturally, we need to change our habits in order to resolve this troublemaking dysfunction permanently. The patient needs to be “long through the neck”, gently raise the scapula by pulling it up and into upward rotation (with the trapezius, NOT with the levator scapulae), and stay there. Forever. Yes, FOREVER – the sooner you start, the sooner you’ll get used to it. It will be uncomfortable and you will get tired in the beginning, but it will pass. And so will its associated maladies!
We just pull it up, straight up toward the sky. Not back, not forward. Just up.
It is very common to over-correct the scapula in posture. Here’s a good example of excessive rigidity, which we do not want. The scapula is too retracted and too externally rotated. Resting height is good, not a problem there. But, there should be at least 15 degrees more anterior tilt and 20 degrees more medial rotation, fitting with the oval shape of the thorax. Speaking of thorax, we can also see that the thoracic spine is slightly too extended for being an optimal foundation for the scapula. It should come down a little.
The cause of scapular dyskinesis
There are many theories of what causes scapular dyskinesis. The main theory is “weakness” of the muscles that perform the actions which the scapula isn’t able to do, and that if we strengthen those, the scapular dysfunction will go away.
I certainly do NOT agree with this.
You see, muscles- they do what we tell them to do. If a muscle is weak, that’s because it’s not being used. In other words, we aren’t habitually using those muscles. I’ve touched upon it already, how scapular depression in posture will promote dyskinesis. When the scapula drops down in posture, it’ll start winging. And winging is immediately cured, NOT by mere strengthening the serratus anterior, like many people mistakenly claim, but by raising the shoulders into proper position, and staying there!
In reality, scapular kinematics will often correlate with the position of the thorax. If the thorax is situated directly above the pelvis, the head and neck will usually be instinctively nice and straight, and it will fall naturally to keep the scapula pulling gently towards the posterior portion of the occiput by utilizing the trapezius muscle.
However, in swayback posture, the pelvis will be forward and chest backward. This forces the head and shoulders forward, to maintain equilibrium, i.e a compensation initiated purposely by the nervous system. Thus, if the thoracopelvic alignment is not addressed first, we may find ourselves working against the nervous system rather than with it if we try to optimize neck and shoulder alignment without also addressing and correcting the before-mentioned, that is, to get the pelvis backward and thorax forward (read more about this in my lower back article).
Not surprisingly, especially when considering the above-mentioned, does also researchers find a TREMENDOUS correlation between rotator cuff injuries (which we know are related to scapular dyskinesis) and postural deviation!
Prevalence of rotator cuff tears was 2.9% with ideal alignment, 65.8% with kyphotic-lordotic posture, 54.3% with flat-back posture, and 48.9% with sway-back posture. Logistic regression analysis identified increased age, abnormal posture, and past pain as factors associated with rotator cuff tears. – Yamamoto et al., 2015
Scapular kinematic alterations similar to those found in patient populations have been identified in subjects with a short rest length of the pectoralis minor, tight soft-tissue structures in the posterior shoulder region, excessive thoracic kyphosis, or with flexed thoracic postures. Ludewig 2009
The group distinguished by a short pectoralis minor demonstrated scapular kinematics similar to the kinematics exhibited in earlier studies by subjects with shoulder impingement. These results support the theory that an adaptively short pectoralis minor may influence scapular kinematics and is therefore a potential mechanism for subacromial impingement. – Borstad et al., 2005
It is therefore my belief, and I have anecdotally confirmed this with a very high success rate clinically, that swayback posture combined with scapular depression and forward head posture is the main cause of scapular dyskinesis.
Why improper scapular mechanics cause injury
I have touched upon this already, but it’s important to understand why the glenoid must syncronize with humeral articulation.
Firstly, there are the strict biomechanical factors. If the scapula downwardly or anteriorly rotates during humeral abduction or flexion, the humeral head, supraspinatus and subacromial bursa will almost inevitably be crushed into the acromion. The picture below illistrates how the humeral head will jam into the acromion if the glenoid’s angle (upward rotation) is insufficient, as well as how the bursa and supraspinatus will compress between the two. If the humerus is in internal rotation, the lateral rotators (teres minor, infraspinatus) may crush into the acromion. Contrarily, if it’s externally rotated, the subscapularis tendon may do so, and over time become injured. This only happens, however, if there is insufficient upwards rotation in relation to the angle of the humerus.
For someone who performs lots of overhead work, e.g a professional roof painter, such a scapular dysfunction will likely lead to injury relatively fast. For someone sitting at a computer all day and is not otherwise involved in strenuous shoulder articulation, the risk of injury will [of course] be considerably lower.
Furthermore, inadequate medial rotation and posterior scapular tilt may cause the humeral head to jam into the coracoid process, creating a situation called coracoid impingement syndrome. Certain individuals may be predisposed to this condition due to having a longer and/or more angled coracoid process, increasing its potential of jamming into the humeral head during flexion.
I have seen patients with completely ruptured (long head) biceps and subscapularis tendons due to coracoid impingement. It can be pretty bad. And fixing it surgically won’t solve the condition, as the patient – unless changing his or hers scapular movement pattern – will keep jamming the humeral head into the coracoid. The solution to this condition is to increase medial rotation and posterior tilt during shoulder flexion and horizontal adduction. I have seen long standing pain patterns immediately resolve as medial rotation is increased during GH articulation.
Coracoid impingement syndrome is a less common cause of shoulder pain. Symptoms are presumed to occur when the subscapularis tendon impinges between the coracoid and lesser tuberosity of the humerus. It is the variation in the height and length of the coracoid process in most cases that is responsible for altering the size and shape of the space between the coracoacromial arch and the rotator cuff. – Okoro et al., 2009
Secondly, there are significant neuromuscular consequences of scapular instability. Scapular dyskinesis weakens and often injures the rotator cuff, as we have seen. Similar to hip dysfunction, when the rotator cuff becomes weak, the whole limb may become compromised. The nervous system will not allow full strength on an insecure foundation (i.e unstable scapula, rotator cuff, or both), which is why continuous scapular dysfunction often will cause inhibitory effects in the whole limb, and not just in the shoulder joint.
The protracted scapular position creates many of the dysfunctional problems associated with chronic AC separations, including impingement and decreased demonstrated rotator cuff strength. – Roche et al., 2015
The clinical examination that addresses scapular posture and includes scapular retraction will allow more accurate determination of absolute supraspinatus muscle strength and allow efficacious rehabilitation protocols to address the source of the demonstrated weakness. – Kibler et al., 2006
The potential adverse effects of scapular protraction on shoulder rotation strength should be considered during the evaluation and treatment of shoulder pain. – Smith et al., 2006
For example, the supraspinatus will often no longer be able to pull the humeral head into abduction, as it should. This will cause superior translation of the humeral head, and exacerbate any existing dysfunction. Even after optimizing scapular movement, something like this would need very specific rehabilitation to fully resolve, so that the humeral head is no longer being forced upward into the acromion due to lack of arthrokinematic rotation (that the supraspinatus should cause).
Additional research on scapular dysfunction
The purpose of this study was to describe normal three-dimensional scapular orientation and associated muscle activity during humeral elevation. Digitized coordinate data and surface electromyographic signals from the trapezius (upper and lower), levator scapulae, and serratus anterior were collected at static positions of 0, 90, and 140 degrees of humeral elevation in the scapular plane. The scapula demonstrated a pattern of progressive upward rotation, decreased internal rotation, and movement from an anteriorly to a posteriorly tipped position as humeral elevation angle increased. Electromyographic activity of all muscles studied increased with increased humeral elevation angles. – Ludewig et al., 1996
Athletes with scapular dyskinesis have 43% greater risk of developing shoulder pain than those without scapular dyskinesis. – Hickey et al., 2017
Relative to the group without impingement, the group with impingement showed decreased scapular upward rotation at the end of the first of the 3 phases of interest, increased anterior tipping at the end of the third phase of interest, and increased scapular medial rotation under the load conditions. – Ludewig & Cook, 2000
Major conclusions were (1) scapular dyskinesis is present in a high percentage of most shoulder injuries; (2) the exact role of the dyskinesis in creating or exacerbating shoulder dysfunction is not clearly defined; (3) shoulder impingement symptoms are particularly affected by scapular dyskinesis; (4) scapular dyskinesis is most aptly viewed as a potential impairment to shoulder function – Kibler et al., 2013
With respect to scapular orientation in the resting position, it has also been demonstrated that individuals with neck pain may display altered postural behaviour, especially when performing prolonged sitting tasks, such as during computer use.29 Increased cervical and thoracic curves and a slouched posture are known to affect scapular orientation, shoulder muscle strength and shoulder range of motion.3 – Cools et al., 2013
Significant group differences were demonstrated for several posture variables, including thoracic spine kyphosis and scapular internal rotation. The distance from the sternal notch to the coracoid process demonstrated the highest correlation with pectoralis minor muscle length. The findings indicate a relationship between posture and pectoralis minor muscle length and support a proposed model linking posture, an anatomical variable, movement dysfunction, and impairment. – Borstad et al., 2006
Compared to nonimpaired subjects (34.6 degrees +/- 9.7), those with impingement demonstrated a significantly lower posterior tilting angle of the scapula in the sagittal plane (25.1 degrees +/- 9.1). Subjects with impingement also demonstrated higher superior-inferior scapular position with maximal arm elevation (5.2 cm +/- 1.6 below the first thoracic vertebrae) compared to nonimpaired subjects (7.5 cm +/- 1.5). – Lukasiewicz et al., 1999
The results of this study demonstrated that tennis players with scapular dyskinesia present a smaller subacromial space than control participants. – Silva et al., 2008
Of the 98 athletes with a positive impingement test, 46 had reduced pain with scapular repositioning. Although repositioning produced an increase in strength in both the impingement (P=.001) and non-impingement groups (P=.012), a significant increase in strength was found with repositioning in only 26% of athletes with, and 29% of athletes without positive signs for shoulder impingement. – Tate et al., 2008
There is evidence of scapular kinematic alterations associated with shoulder impingement, rotator cuff tendinopathy, rotator cuff tears, glenohumeral instability, adhesive capsulitis, and stiff shoulders. There is also evidence for altered muscle activation in these patient populations, particularly, reduced serratus anterior and increased upper trapezius activation. Scapular kinematic alterations similar to those found in patient populations have been identified in subjects with a short rest length of the pectoralis minor, tight soft-tissue structures in the posterior shoulder region, excessive thoracic kyphosis, or with flexed thoracic postures. – Ludewig & Reynolds, 2009
General patterns of shoulder motion observed during humeral elevation were clavicular elevation, retraction, and posterior axial rotation; scapular internal rotation, upward rotation, and posterior tilting relative to the clavicle; and glenohumeral elevation and external rotation. – Ludewig et al., 2009
During shoulder elevation, most researchers agree that the scapula tilts posteriorly and rotates both upward and externally. It appears that during shoulder elevation, patients with SIS demonstrate a decreased upward scapular rotation, a decreased posterior tilt, and a decrease in external rotation. In patients with glenohumeral shoulder instability, a decreased scapular upward rotation and increased internal rotation is seen. – Struyf et al., 2011
The major difference between groups was that the SP group displayed a significant downward rotation of the scapula in almost all shoulder positions. – Green et al., 2013
Fatigue in shoulder external rotation altered the scapular resting position and the movement of posterior tilting in the early range during arm elevation in the scapular plane. – Tsai et al., 2003
Evaluation of scapular movement
Now that you know where the scapula should rest and how to identify general scapular movement, let us discuss normal and abnormal movement patterns. Identifying these are key, because you can not correct something you do not identify.
As mentioned, the glenoid fossa must follow the arm’s movement. This means that during glenohumeral articulation, the following movements should co-occur.
- Glenohumeral flexion with scapular posterior tilt, protraction & medial rotation
- GH extension with scapular anterior tilt & retraction
- GH abduction with scapular upward rotation, retraction & lateral rotation
- GH (ventral) adduction with scapular downward rotation, medial rotation and protraction
- GH (dorsal) adduction with scapular downward rotation, external rotation and retraction
- GH horizontal abduction with scapular external rotation and retraction
- GH horizontal adduction with scapular medial rotation and protraction
ANGLES – The further the humerus moves into a given direction, the greater movement is required by the scapula. In other words, 180 degrees of glenohumeral flexion will require greater posterior tilting (approx. 60 degrees) and medial rotation than 90 degrees will (approx. 30 degrees). This is important to understand.
THORACIC SPINE – During shoulder elevation, the degree of thoracic spinal extension should increase. Thoracic spinal flexion should somewhat increase during GH extension past the torso. Rounding of the upper back during shoulder elevation, especially past 90 degrees, should be considered dysfunctional, but is usually simple to cue the patient out of, meaning fix.
Furthermore, a combination of the above (the bullet-points) will of course occur during diverse movement patterns. The above-mentioned are general guidelines for what should happen. The scapula should not significantly elevate nor depress from optimal position during loading, but it will do so if reaching for something. Furthermore, raising the arm should encourage a slight degree external glenohumeral rotation whilst lowering the arm should encourage a slight degree of internal glenohumeral rotation. This is probably why powerlifters have learnt to “break the bar” when bench pressing to avoid injuries, although most likely unaware of the biomechanical reasons. When pulling, some more internal rotation should occur.
- Pressing motions are associated with greater external GH rotation
- Pulling motions are associated with greater internal GH rotation
Again, general rules! There are no absolutes, but I do think that these guidelines are pretty well based and quite beneficial to follow.
Optimal scapular movement
Now, let us look at the most common movement patterns. When correcting scapular dyskinesis, we need to be able to see when it deviates from proper motion, and push it back in there manually. This is not something you learn over night, but something that’s digested, understood, and improved gradually in practice. It all starts with a decent understanding of when which movements should occur and what this looks like.
NB: A prerequisite for good movement is always proper scapular resting position. If you don’t know how to evaluate resting position, don’t expect to get good at identifying nor correcting scapular movement. I won’t mention this further in the movement sub-headings (unless I forget, which I might. Empty threat.)
When assessing scapular movement during shoulder abduction, the upper trapezius should engage simultaneously with the supraspinatus and medial deltoid as the arm abducts. This is because upward rotation and GH abduction go hand in hand. There should NEVER occur reflexive downward rotation upon initiated elevation of the arm. The scapula should not significantly elevate during GH movement either, especially not during loading. It should remain stable, situated tightly on the thorax.
There is, as mentioned, a 3:1 ratio between GH and scapular movement. The scapula should rest at approximately 0-10 degrees of upward rotation before abduction is initiated. At 90 degrees of GH abduction, there should thus be approx. 30 degrees of upward rotation. And so on.
To identify upward rotation you can use an inclinometer app on your smartphone (learned this trick from professor Ann Cools of Ghent university in Belgium), until you’re able to evaluate it without any additional tools, which you will eventually. You apply the inclinometer on the spine of the scapula, or use your index finger on the medial and lateral parts of the spine of the scapula, and measure its angle compared to glenohumeral angle. Again, it should be about 30% of glenohumeral angle.
I’ll display this illustration once more, because it’s shows the point very well.
When assessing shoulder flexion, the first thing that should occur when the patient raises the arm forward, is slight protraction and posterior tilting of the scapula. There should never be winging upon or during initiation of GH flexion. The scapula should remain at a stable height.
The same principle apply here as above; the greater the angle of the humerus, the greater the angle of posterior tilting is required. We need approximately 60 degrees of posterior tilting at 180 degrees of GH flexion. This, however, is impossible because the inferior scapular angle will crash into the ribs, if posterior tilt is to be the only movement that occurs! This is where protraction and medial rotation comes in. The scapula protracts and medially rotates, and now posterior tilting happens on an oblique angle on the posterolateral aspect of the thorax, so that the inferior angle do not jam into it. This may be a little difficult to understand, but as long as the scapula protracts and medially rotates as it posteriorly rotates, you’re fine.
To evaluate posterior tilting, put one finger at the superior angle and one on the inferior angle of the scapula. Compare its perceived angle with GH flexion.
Below is a good example of proper humeral rotation during shoulder pressing in the coronal plane. The elbows are somewhat anterior/directly below the wrist, indicating proper degree of lateral rotation of the glenohumeral joint. External rotation of the GH promotes upwards rotation and posterior scapular tilt. INTERNAL GH rotation (elbow posterior to wrist) promotes the opposite. A lot of people will excessively medially rotate the humerus during pressing motions, predisposing them to injury as well as (releative) weakness.
For the horizontal press, the same principles apply. Elbow beneath wrist, not anterior and ESPECIALLY NEVER posterior to the wrist (once again, because it promotes anterior tilt and downward rotation). The humerus should be adequately externally rotated. If it’s too externally rotated, it’ll become a triceps extension rather than a press, and strength is lost. Excessive external rotation will rarely cause injury though, just loss of potential, meaning strength loss.
The wider the grip, the less external rotation is “adequate”, and the opposite for a more narrow grip. In other words, greater E.R is required for narrow grip than wide grip, in order to meet the requirement of elbow beneath wrist. Thus the gentleman above, who is pressing in the coronal plane, requires less E.R than someone performing a proper close-grip bench press, in the sagittal plane.
Scapula “back and down” and the costoclavicular space
A short note on this abomination of a cue! It is often (always) said that the scapula should be pinched back during the horizontal press. It is often used in other circumstances as well, but especially for the bench press and similar.
As you have learned in this article, the scapula should only retract when the arm is parallell with or behind the body (e.g. more than 90˚ of horizontal abduction). Retracting the scapula when the arms are adducted and flexed, as in the bench press, will cause the humeral head to jam into the coracoid process, as there in inadequate medial rotation. Further, although many get good at doing stupid things, optimal strength will never be achieved with the scapula pulled away from the thorax. Contrarily, optimal strength occurs when the scapula is situated snugly onto the thoracic wall, in proper position, which is mild medial & upwards rotation with slight protraction. Approximately as shown in fig. 14, should the scapulae be situated during the bench press.
I suggest that you get a Donnie Thompson’s Fat Pad bench press pad, as the tiny useless benches are simply too narrow for proper scapular mechanics.
Pulling back and down will also, for certain predisposed individuals (especially those with TOS or very depressed scapular resting position), cause costoclavicular space syndrome, as it will cause the collar bone to crush the brachial plexus, subclaivan artery and vein between itself and the first rib. This can cause plexopathy, i.e. nerve injury and significant problems, and must therefore not be done.
In our experience, droopy shoulder syndrome has accounted for most cases of thoracic outlet syndrome but is largely unrecognized by physicians. Recognition of this syndrome should lead to a better understanding of the underlying pathophysiology and prevent unnecessary surgery. – Swift & Nichols, 1984
Thoracic outlet syndrome (TOS) is a symptom complex attributed to compression of the nerves and vessels as they exit the thoracic outlet. Classified into several sub-types, conservative management is generally recommended as the first stage treatment in favor of surgical intervention. In cases where postural deviations contribute substantially to compression of the thoracic outlet, the rehabilitation approach outlined in this masterclass will provide the clinician with appropriate management strategies to help decompress the outlet. The main component of the rehabilitation program is the graded restoration of scapula control, movement, and positioning at rest and through movement.
The conservative physiotherapy regimen outlined in this article will be suitable for patients presenting with TOS where there is a strong postural contribution to their symptoms. In particular, in cases of TOS where the scapula mechanics are poor and the patient presents with the dropped shoulder condition (scapula depressed and/or downwardly rotated, and/or anteriorly tilted) (Ranney,1996).
Many forms of scapula asymmetry may well exist in TOS populations, but in the limited research that has been done, scapula or shoulder girdle depression or “drooping” has been consistently observed (Kenny et al., 1993; Walsh, 1994; Pascarelli and Hsu, 2001; Skandalakis and Mirilas, 2001). Scapula depression will lead to
Scapula depression will lead to an alteration of the anatomical alignment of the structures in both the cervical and thoracic outlet (Telford and Mottershead, 1948; Kai et al., 2001; Skandalakis and Mirilas, 2001) (Fig. 2). It may potentially lead to tractional stress being placed on the nerve, vascular and muscular elements as well as compression as the clavicle descends closer towards either the first rib or any other bony element present. Elevation of the shoulder girdle can alleviate these stressors and potentially lead to “decompressing” the thoracic outlet (Kitamura et al., 1995).
One of the consistent objective findings that we have observed and measured in cases of sTOS is that the scapula can be depressed at rest (Fig. 3) on the symptomatic side compared to the other side (in unilateral TOS) and to the normative data in cases of bilateral TOS (Kai et al., 2001). Increased anterior tilt of the scapula is also commonly identified in sTOS (Sucher, 1990; Aligne and Barral, 1992; Press and Young, 1994; Walsh, 1994) and it is frequently coupled clinically with increased downward rotation of the scapula. – Watson et al., 2010
There’s a different between shoulder extension in a loaded pattern, and extension past the torso. Significant anterior scapular tilt should occur during past-torsal extension, but NOT during loading, where the elbows remain either ventrally or on the side of the torso, like with a seated row or pull-down. The lats (& teres major) do not pull the elbow further back than to the torso! Further movement will target scapular retractors, posterior deltoid as well as the long head of the triceps.
During a loaded pattern such as a lat pull-down, the scapula should still be in optimal starting position when the arms are raised. They shouldn’t elevate or “stretch”. During pull-down, or pull-in (rowing) for that matter, i.e the concentric phase of the exercise, the scapula will stay relatively posteriorly tilted and upwardly rotated as it was during starting position. This may seem somewhat contra-intuitive, but it should remain stable when loaded and not have excessive motion.
Fig. 24 – proper scapular starting position for the pull-down exercise
During true GH extension past the torso, we see that maximal retraction and significant anterior tilt should occur. The anterior tilt isn’t as visible as it should be, but this was by far the best demonstrating picture that I could find.
Honestly, I rarely have to assess this movement. The patient will usually manage on their own. Sometimes, for example in skiers with thoracic outlet syndrome, I need to make sure that the clavicle do not drop too low during shoulder extension, as it will both crush the brachial plexus as well as make them weaker. Proper execution of loaded pulling such as the row or pull-down is a far more relevant but also difficult assessment, and is one I do much more often.
Here’s a few videos of my chubby self demonstrating scapular kinematics during a few different exercises. You may have to watch these over, and over until you understand the concept of scapular rotation in practice. That’s how I learned. I’ll show more videos further down, in the corrective section.
Dysfunctional scapular movement
Now, let us learn how to identify the most common dysfunctional scapular kinematic strategies.
It’s important that you first understand what proper movement is and what it looks like, because I simply can not cover all possible details in this section. Once you really get a deep understanding of proper movement, you will easily catch any deviation from it and guide the patient back into proper patterning.
That said, improper movement is basically anything that opposes with what you learned in the the former sub-heading. Downward rotation during abduction, scapular depression or elevation in loaded patterns, anterior tilting or external rotation during shoulder flexion, and so on. The dysfunction often presents itself upon initiation of abduction, or at the descent, i.e the eccentric portion of abduction. It is very important to teach the patient to control both concentric and eccentric movements properly.
As I said, during abduction, the scapula should upwardly rotate without elevating nor depressing significantly. In the picture below, we can see proper upward rotation in the left shoulder complex, but dysfunction in the right one. Can you describe the dysfunction in detail based on what you’ve learned so far? Take a sneak peak and try, before you read the next sentence.
The right scapula is elevated, downwardly rotated and anteriorly tilted. Remember what muscles that does this? The levator scapulae! So this patient is over-using his levator scapulae rather than his trapezius and serratus anterior, i.e he needs more posterior tilt and upward rotation.
This patient needs to be manually put into slight depression by pulling the glenoid posteriorly and the superior angle inferiorly, so that the scapula slightly upwardly rotates and is in proper height. He must then learn to stay there during abduction. The therapist carefully measures the scapular movement and corrects any deviation, until the patient learns to stay there and feel what’s right and wrong for himself.
More commonly it will depress and downwardly rotate, which is an indication of excessive usage of the pectoralis minor and lack of facilitation of the trapezius complex and serratus anterior. In this case we can also see that the scapula is medially rotated even though it is retracted. This shouldn’t happen, so there is significant dysfunction in this individual’s scapular movement.
The scapula requires slight elevation, as well as a lot of upward rotation, some lateral rotation and posterior tilting, in order to properly align with the angle of the arm. Also here, the therapist must passively pull the scapula into proper position and let the patient retry the movement. This procedure is repeated again and again until the patient learns the proper scapular movement pattern. This may take days, weeks or months, depending on severity as well as the patient’s own proprioceptive ability and understanding of the problem itself.
For flexion, it is much the same. The scapula should protract, medially rotate and posteriorly tilt significantly. Some upward rotation will also occur due to the combination of posterior tilt during protracted scapular position, i.e the posterior tilting at an oblique angle that I mentioned earlier.
In the picture below we see the epitome example of scapular kinematic dysfunction during a horizontal pressing motion. Firstly, at resting (static loading) position, we see that the scapula is too retracted and downwardly rotated – this is strongly indicative of the trouble to come.
During the pressing motion, to the right, a confirmation of my woeful dyskinetic scapular prophecy is seen (yes, I make scapular prophecies – deal with it). Severe dyskinesis is observed as the deltoid pulls the scapula down due to lack of opposing pull by the serratus and trapezius muscles, as I mentioned briefly in the scapular kinematic and functional anatomy sections. Although the scapular height is decent at the static position to the left, it is now greatly depressed at end range. Furthermore, we see tremendous anterior tilting, downward rotation and also a somewhat excessive medial rotation that looks to be at least 60 degrees – (If the arm is working in the sagittal plane, i.e 90 degrees of horizontal adduction (from the coronal plane), this would indicate a need for approx. 30 degrees of medial scapular rotation).
This patient needs to be taught, first of all, to maintain tension in his upper trapezius during pressing motion. When the scapula falls, all other stabilizers usually fail as well (which is why I do NOT agree that the serratus anterior is a primary culprit nor priority). He must be passively put into proper height and slight protraction, and try again (and again, and again), while maintaining tension in the muscles that uphold such a position (trapezius, levator scapulae (if scap. is depressed, the latter is usually inhibited as well), serratus anterior). He must be taught to co-contract the scapular stabilizers AND the deltoids & pectorals, so that these do not pull the scapula out of proper position (anterior and medial deltoid as well as pectorals pull the scapula into anterior tilt and downward rotation if not opposed by scapular stabilizers. Functional anatomy, as mentioned earlier.)
Once again, some external glenohumeral rotation is a natural part of shoulder flexion and abduction. In the picture below we can see decent activation of the serratus anterior, and most likely this person has a relatively good scapular angle based on the looks of it (rare – but does happen from time to time). But the point here is to pay attention to the massive, inappropriate medial humeral rotation (a digression, but the wrists are bad too).
The elbows should be pointing more forward, at least 15 degrees more. This is basically abduction (coronal plane pressing), which is why it’s “only” 15 degrees more. If it was flexion (sagittal plane pressing), or something in between, i.e greater horizontal adduction; a higher degree of lateral GH rotation would be required, meaning the elbows would need to point [much] more forward.
Here is a similar example for the horizontal press. Elbows are posterior to the wrist, and is also pointing backward, which is a tell-sign of inappropriate medial humeral rotation during pressing motions. You will almost always see patients who hurt themselves during benchpress have a technique similar to this.
Sometimes it is a mere elbow issue, i.e technique problem and not dyskinesis. Simply have the patient tuck their elbows (externally rotate) to adequate degree, and teach them to stay in a relative position during execution. This will also benefit their triceps strength.
Now, this is not really active extension because he’s resting his arm on the lower back, but I couldn’t find a better demonstrative picture. Let’s imagine that he did actively pull the arm backward actively into extension.
In such a case, the severe scapular depression and winging is a clear sign of dyskinesis during extension. The rhomboids, who retracts and laterally rotates as well as the levator scapulae, who anteriorly rotates, and elevates, are evidently not doing their jobs. The scapula requires greater retraction, external rotation and elevation.
Teaching extension is a lot easier than teaching abduction and flexion. That said, this patient must be taught to pull the scapula back and up, mainly using his rhomboid. This should co-occur in normal kinematic sequences for GH extension.
Finally, I will address how we should be correcting faulty scapular movement. As I am sure you’ve understood by now, we can not simply train the non-responding muscles and expect everything to sort out on its own; it won’t! There are so many people claiming otherwise, but I can assure you that this belief is founded on dogma and not on real, long term results with clients.
Strengthening exercises alone are close to useless for addressing motor dysfunction!
It is my belief and clinical experience that the commonly used exercises barely have any affect at all, until proper scapular stability has already been established. When dyskinetic, will not properly stimulate the scapular stabilizers; quite the contrary, it’ll just exacerbate the dysfunction because the patient will not be able to perform the exercises properly.
Why not? – Think, for a second. Think critically.
If the patient is not able to access the proper muscles during an UNLOADED pattern such as humeral elevation or control protraction against a wall. How much LESS would he or she be able to access these muscles in a LOADED pattern for such a muscle group? It won’t happen! And once again, believe me when I say; I have tried! I do not advocate a more difficult approach just for the fun of it – I do it because it works (and it also makes a lot more sense, in my opinion.)
Let’s take the serratus anterior as an example. The serratus anterior pulls the scapula into protraction, medial & upwards rotation as well as posterior tilt. Now, if the patient performs a scapular push up for example (I will link a video for proper execution further down), and those movements aren’t happening, is he stimulating the serratus anterior? Of course not. Mere protraction and some fibrous stimulus of the S.A does not equal proper function.
If you tell a person with scapular dyskinesis to perform scapular push-ups, even standing against a wall (minimum resistance), the scapula will still tilt anteriorly and rotate downward during protraction, because they’re using the wrong muscles! I HAVE TRIED, MANY TIMES! Scapular movement must be optimized before strengthening exercises can be efficiently commenced.
Here is an example of this, and although this isn’t the best (read: worst), it was the best one I could find online. The person is trying to perform scapular push-ups, but we see significant anterior tilting and thoracic spine flexion; a dysfunctional pattern which will not support proper scapular mechanics during horizontal loading. For a person with significant scapular dyskinesis, there will be much more dysfunctional movement than what’s seen below, within the whole range of motion, stimulating everything else than what’s attempted.
EMG studies “proving” an exercise’s efficiency are equally useless in my opinion. The reason is that such efficiency depends on proper motor control! Using a “proven” exercise for a patient who is not able to posteriorly tilt or upwardly rotate the scapula even in an unloaded position, will not work. It will, however, work for someone who has proper control when unloaded, but experiences scapular dyskinesis only when the weights increase. We have to differentiate between motor control dysfunction and strength deficits.
Let us stop the madness; we must optimize scapular mechanics first. Then strengthen the muscles.
How to really correct scapular dyskinesis
Learning new habits is the true key to great and permanent results with regards to scapular kinematic dysfunction. Establishing proper motor control will subsequently cause habitual stimulus and maintenance of the muscles that are commonly inhibited, such as the trapezius and serratus anterior, because they are now being used in daily life. The patient has to learn what proper movement is, in detail. Only then can long term results be guaranteed, in my experience.
Working with motor control is not easy, and may be frustrating for the client. The “worse” ones, i.e the ones with severe dyskinesis, will rarely feel the difference between right and wrong kinematics, and do not have control of the muscles causing the proper movement. It is very important to be patient, and keep working on it. It WILL get better as long as the patient doesn’t give up.
Here is how I do it:
- Teach proper resting position
- Guide scapular movement during abduction and flexion in below 90 degrees of elevation
- Guide scapular movement during abduction and flexion in above 90 degrees of elevation
As mentioned many times in this article, resting position is key to proper scapular mechanics. First, evaluate the patient’s resting position. Is it above or below the T2? is it too externally rotated (less than 30 degrees)? Is it too anteriorly tilted (more than 20 degrees)? Too downwardly rotated (more than 0 degrees)? is the scapula too retracted or too protracted? Is the T-spine too flexed or too extended? Is the head too forward? Is the pelvis in front of the thorax? Correct the scapula according to what you have learned in this article, and tell the patient to stay there.
I don’t usually correct all of these small details, as there’s no such thing as PERFECT. We are human. But it can get pretty good with the right approach, and with pretty good I mean 90+%. Let’s make a relevant case study. The posture below, from figure 16 is the type that I most commonly see at my office – what should be done?
Once again, we can see that there’s great anterior tilt and downward rotation of the scapula. Furthermore, it is in severe depression. When the trapezius inhibits, winging is almost inevitable. This can easily be reversed by gently pulling the glenoid upward in posture, if the patient is willing to put the work in. With one hand on the medial border of the scapula and one hand on the upper arm, I pull the scapula slightly up (elevate) and into slight upward rotation. I’ll tell the patient to stay there, and release my hands.
The patient will feel very tense and rigid. Most of them say “I can’t stay like this, you can’t be serious”. But yes, “I am very serious, and yes you can”. It looks a little silly because they’re not used to it, but within a couple of weeks it’ll feel like they’ve been doing it all their life. It’s all about getting used to a new habit. Missing this step will not produce lasting results, and it will make it extremely hard to correct the movements themselves.
It will be uncomfortable, and it will require a real effort. Don’t tweak when you tell your client what to do, because if you seem insecure, they won’t do it! It’s just too uncomfortable for them, and too different from what all other therapists are saying. You need to be confident in your correctives in order to motivate your patients to put the work in.
Additionally they should be assigned an exercise for the upper trapezius, i.e a shrugging motion either with a band or some other kind of weighted resistance. Shrugging is simple and do not require scapular re-patterning in advance. I do not give exercises for the serratus anterior or lower trapezius in this stage of treatment, because they will not (well, rarerly) be able to do it properly.
Below is a picture that a patient sent me, who had severe shoulder pain, thoracic outlet syndrome (as the clavicle was crushing the brachial plexus), scapular dyskinesis and “chronic” bursitis. We can see that the scapula is resting extremely low. She was taught to raise the shoulders in posture by gently activating the trapezius muscle, i.e gently elevate and upwardly rotate the scapula in posture. Well, I write gently, but the scapular depression this patient had was so severe that we needed to raise the shoulder girdles significantly.
Also notice that the trapezius is seemingly very large, and upon palpation it had a high tone as well. Yet, if we think about it, why would be scapula be hanging down if it was functional? It wouldn’t! So, don’t let your eyes mislead you. Base your corrections on the whole picture, not on fragments. Furthermore, studies have shown that weak muscles sometimes hypertrophy yet prove very weak upon strength testing, and such a case was also seen here. I’ll leave a very interesting and hopefully enlightening quote below.
On the symptomatic side the gluteus maximus was far more active compared with the healthy subjects. The reciprocal relation between latissimus and gluteus maximus muscles, however, was still present (Mooney et al. 2001). Despite the increased activation of gluteus maximus, patients with SIJ dysfunction demonstrate significant weakness in the muscle (Massoud Arab et al. 2011). – Vleeming et al., 2012
The patient was very eager to get going with proper correctives, and just two weeks later I was sent this follow up picture. The scapula is now very well situated on the thorax, with proper elevation and upward rotation. We, of course, also worked on proper scapular movement, which I will talk about next.
The correctives for movement is separated by glenohumeral articulation below and above 90 degrees, as mentioned above. Many people will struggle the most below 90 degrees, both in starting movement as well as during eccentric movement. The wall slide exercise can be good for teaching both portions of the movement, and I will show it later. But let us first start with GH articulation below 90 degrees.
When teaching proper scapular kinematics in the first 90 degrees of movement, either abduction or flexion or a mixture of the two, I’ll first see that they’re in proper resting position. I will assess abduction and flexion separately.
Starting with flexion, once the patient initiates the movement, I am looking for scapular winging and/or depression. If this occurs, stop the patient, relocate the scapula manually, and tell them to continue up unto 90 degrees. On the way down, once again look for deviations from optimal alignment. Every time the patient falls out of proper position, relocate the scapula for them by pulling the lateral margin up and back, and ask if they can feel the difference. Sometimes they can, other times not. The ones that feel the difference of your corrections are the ones that are going to get better, faster, and with less frustration.
You will repeat this process over and over and over until the patient learns to do it themselves, and to feel the difference between proper and improper movements. Once they can feel the difference between improper and proper movement, give them a 2-4lb dumbbell and restart the process. Continue in this fashion for the weeks to come, gradually increasing the weights.
For abduction, it’s pretty much the same thing. Watch for depression and downwards rotation as the patient abducts the arm. There should not be much movement of the scapula until 90 degrees, but it should remain at about 10-20 degrees of upward rotation. The most common problem is either elevation or depression combined with downward rotation in the beginning phase as the arm abducts. If the patient overly upwardly rotates or elevates in the beginning, although not optimal, clearly it is superior to downward rotation and depression, as the latter will cause impingement whereas the former will not.
If it elevates, pull the superior angle down and elevate the lateral margin. If it depressed, use the same corrective as above, namely by pulling them up at the inferior angle and lateral margin of the scapula. When it’s in the proper position, let the patient try to stay there as the movement is carried on or restarted.
During eccentric movement, the patient will often release (deactivate) the trapezius and lock the scapula with the deltoid, pulling it into downward rotation on the way down. They must be taught to dissociate between scapular and humeral movement (Osar, 2012). Tell them to relax the deltoid as you passively upwardly rotate the scapula, and let them lower the arm. Repeat until the patient understands the proper movement pattern.
Also here, a 2-4 lb dumbbell or similar can be used once the unloaded pattern is looking good. Gradually increasing the weights over time, usually over a couple of months. The goal is to use the same weights as before starting rehabilitation, but with proper scapular mechanics. Well, even higher weights now that the patient is pain free!
The wall-slide exercise is a pretty good way to learn how to move the scapula, because it encourages proper movement slightly more than free movement. Don’t, however, expect the client to do it perfectly all alone. You will still need to continuously evaluate and correct scapular movement during this exercise. They will have slightly more control when tracking the wall with their elbows, than they will by moving the arm in thin air, which is why it may be beneficial as homework in the starting phase of rehabilitation.
For movements above 90 degrees, I like to use the unilateral shoulder press exercise. Start without any weights, just the pressing motion. The main issue here is often resting position; they will attempt to rest in scapular depression & winging, which is a horrible foundation for vertical pressing. Relocate the scapula into proper position by pulling it up (one hand in armpit, one pushing at the inferior angle) and back (back as in posteriorly rotate). Now cue the client to stay there and feel stable before initiating the pressing motion.
Once proper loaded resting position is maintained, watch the client elevate the arm. The scapula should not fall down nor excessively elevate. In the video below you see that I do not lock out my arm, which is because I lack the flexibility. If I were to lock it out, it would be at expense of elevating the scapula and medially rotating my arm (in order to reduce tension in the lats and teres major). I do not recommend this because it doesn’t provide a secure foundation for potential of maximal power and stability.
The exercise for the lower trapezius is quite difficult, but very effective once the client can properly move the scapula. Start with very low weights, and make sure that the scapula moves properly during the full range of motion. It is especially challenging to control on the descent, i.e eccentric part of the lift. This is, however, a great way to get [relatively] strong in a position of inevitable weakness. If the client can learn to control this motion with weights, chances are they will never go back to improper movement patterns again.
For horizontal pressing, we need to once again watch the resting position of the scapula. If the patient starts in a push-up stance, the scapula will usually “hang” backward, i.e overly retract, and stay like that during the eccentric portion (lowering) of the exercise. Concentrically, the dysfunction will reveal itself in winging and scapular depression. Almost as seen below, but in reverse. The principle is the same.
First of all, don’t start in a horizontal pushup position, this load is too great for someone with scapular dyskinesis. Start standing up, pushing against a wall. This is a realistic simulation with a low load. Teach them proper starting position, i.e protracted with proper scapular alignment. The scapula should not fall into retraction the very second that the patient lowers himself into the wall, but rather stay relatively protracted and properly aligned until the elbow is lateral to the torso (remember that excessive retraction should be co-occurring with maximal extension or horizontal abduction). Only when the elbow passes behind the torso should the scapula retract, and it should immediate protract once the elbow is lateral to the torso once again (in concentric motion). Maintaining tensegrity is key.
To help with this, the patient can be taught how to properly perform a scapular push-up. It will often be very difficult to maintain protraction without excessive anterior tilting (pectoralis minor). By passively assisting the patient in proper alignment of the scapula, perform low-weighted (standing) protractive motions of the scapula without losing optimal alignment. Once performed properly when standing up, it’s possible to gradually increase the angle and thus the weight by performing the exercise onto a box or something similar.
Fig. 38 – Relocate the scapula when it elevates and anteriorly rotates
Ultimately, on the floor, with weights on the back, performing a full push-up with proper scapular mechanics.
This article became a lot longer than I expected when I started writing it. Although the correctives themselves are relatively straight forward, the key is to understand the scapular movements and what optimal movement as well as resting position should look like. Only then can the therapist confidently guide the patient’s scapular movement with success. The background knowledge for being able to identify these elements are the reason why this article “had” to be so long.
The most important information in this article can be summed up as the following: Scapular resting position is extremely important – it is a main key to resolution, as well as an important co-contributor of scapular dyskinesis. The scapula should rest approximately in line with the T2 vertebrae, and it should be 0-10 degrees upwardly rotated in normal posture. Forward head and swayback postures will affect scapular position and must be addressed if necessarily. Exercises can not fix postural dysfunction, only habitual changes, i.e raising the scapula into proper position and staying there.
Furthermore, strengthening exercises can not resolve scapular dyskinesis. Motor re-patterning is necessary, and will lead to great success when done properly. The patient must first learn to move the arm in diverse directions with proper scapular movement UNLOADED, and later in a loaded manner. In order to correct these movements, the therapist must have a thorough understanding of proper scapular kinematics and how to assess these.
Taking on a new posture and practicing new movement patterns may be difficult, uncomfortable, frustrating and demotivating for the patient. Patience and persistence is necessary. The therapist must be confident and not tweaky, as this might discourage the client.
- Osar E. Corrective exercise solution to common hip and shoulder dysfunction. Lotus Publishers; 2012
- Zakharova-Luneva E, Jull G, Johnston V, O’Leary S. Altered trapezius muscle behavior in individuals with neck pain and clinical signs of scapular dysfunction. J Manipulative Physiol Ther. 2012 Jun;35(5):346-53. doi: 10.1016/j.jmpt.2012.04.011. Epub 2012 May 17. PMID: 22608287.
- Swift TR, Nichols FT. (1984). The droopy shoulder syndrome. Neurology 34, 212- 215.
- Hooper TL, Denton J, McGalliard MK, Brismée JM, Sizer PS Jr. thoracic outlet syndrome: a controversial clinical condition. Part 1: anatomy, and clinical examination/diagnosis. J Man Manip Ther. 2010 Jun;18(2):74-83. doi: 10.1179/106698110X12640740712734.
- Saxton EH, Miller TQ, Collins JD. Migraine complicated by brachial plexopathy as displayed by MRI and MRA: aberrant subclavian artery and cervical ribs. J Natl Med Assoc. 1999 Jun;91(6):333–341.
- Kibler WB, Sciascia A, Wilkes T. Scapular dyskinesis and its relation to shoulder injury. J Am Acad Orthop Surg. 2012 Jun;20(6):364-72. doi: 10.5435/JAAOS-20-06-364. PMID: 22661566.
- Uhl TL, Kibler WB, Gecewich B, Tripp BL. Evaluation of clinical assessment methods for scapular dyskinesis. Arthroscopy. 2009 Nov;25(11):1240-8. doi: 10.1016/j.arthro.2009.06.007. PMID: 19896045.
- Ludewig PM, Braman JP. Shoulder impingement: biomechanical considerations in rehabilitation. Man Ther. 2011;16(1):33-39. doi:10.1016/j.math.2010.08.004
- Ludewig PM, Phadke V, Braman JP, Hassett DR, Cieminski CJ, LaPrade RF. Motion of the shoulder complex during multiplanar humeral elevation. J Bone Joint Surg Am. 2009 Feb;91(2):378-89. doi: 10.2106/JBJS.G.01483. PMID: 19181982; PMCID: PMC2657311.
- Tsai NT, McClure PW, Karduna AR. Effects of muscle fatigue on 3-dimensional scapular kinematics. Arch Phys Med Rehabil. 2003 Jul;84(7):1000-5. doi: 10.1016/s0003-9993(03)00127-8. PMID: 12881824.
- Sahrmann, S.A. Diagnosis and Treatment of Movement Impairment Syndrome. Mosby, St. Louis; 2002, 30-31.
- Ludewig PM, Cook TM. Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement. Phys Ther. 2000 Mar;80(3):276-91.
- Yamamoto A, Takagishi K, Kobayashi T, Shitara H, Ichinose T, Takasawa E, Shimoyama D, Osawa T. The impact of faulty posture on rotator cuff tears with and without symptoms. J Shoulder Elbow Surg. 2015 Mar;24(3):446-52. doi: 10.1016/j.jse.2014.07.012. Epub 2014 Oct 16. PMID: 25441565.
- Borstad JD. Resting position variables at the shoulder: evidence to support a posture-impairment association. Phys Ther. 2006;86:549–557.
- Borstad JD, Ludewig PM. The effect of long versus short pectoralis minor resting length on scapular kinematics in healthy individuals. J Orthop Sports Phys Ther. 2005 Apr;35(4):227-38. doi: 10.2519/jospt.2005.35.4.227. PMID: 15901124.
- Okoro T, Reddy VR, Pimpelnarkar A. Coracoid impingement syndrome: a literature review. Curr Rev Musculoskelet Med. 2009;2(1):51-55. doi:10.1007/s12178-009-9044-9
- Roche SJ, Funk L, Sciascia A, Kibler WB. Scapular dyskinesis: the surgeon’s perspective. Shoulder Elbow. 2015;7(4):289-297. doi:10.1177/1758573215595949
- Kibler WB. Scapular involvement in impingement: signs and symptoms. Instr Course Lect. 2006;55:35-43
- Smith J, Dietrich CT, Kotajarvi BR, Kaufman KR. The effect of scapular protraction on isometric shoulder rotation strength in normal subjects. J Shoulder Elbow Surg. 2006 May-Jun;15(3):339-43. doi: 10.1016/j.jse.2005.08.023. PMID: 16679235.
- Ludewig PM, Cook TM, Nawoczenski DA. Three-dimensional scapular orientation and muscle activity at selected positions of humeral elevation. J Orthop Sports Phys Ther. 1996 Aug;24(2):57-65. doi: 10.2519/jospt.19126.96.36.199. PMID: 8832468.
- Hickey D, Solvig V, Cavalheri V, Harrold M, Mckenna L. Scapular dyskinesis increases the risk of future shoulder pain by 43% in asymptomatic athletes: a systematic review and meta-analysis. Br J Sports Med. 2018 Jan;52(2):102-110. doi: 10.1136/bjsports-2017-097559. Epub 2017 Jul 22. PMID: 28735288.
- Kibler WB, Ludewig PM, McClure PW, Michener LA, Bak K, Sciascia AD. Clinical implications of scapular dyskinesis in shoulder injury: the 2013 consensus statement from the ‘Scapular Summit’. Br J Sports Med. 2013 Sep;47(14):877-85. doi: 10.1136/bjsports-2013-092425. Epub 2013 Apr 11. PMID: 23580420.
- Cools AMJ, Struyf F, De Mey K, et al. Rehabilitation of scapular dyskinesis: from the office worker to the elite overhead athlete. Br J Sports Med 2013;00:1–8. doi:10.1136/bjsports-2013-092148
- Lukasiewicz AC, McClure P, Michener L, Pratt N, Sennett B. Comparison of 3-dimensional scapular position and orientation between subjects with and without shoulder impingement. J Orthop Sports Phys Ther. 1999 Oct;29(10):574-83; discussion 584-6. doi: 10.2519/jospt.19188.8.131.524. PMID: 10560066.
- Silva RT, Hartmann LG, Laurino CF, Biló JP. Clinical and ultrasonographic correlation between scapular dyskinesia and subacromial space measurement among junior elite tennis players. Br J Sports Med. 2010 May;44(6):407-10. doi: 10.1136/bjsm.2008.046284. Epub 2008 Apr 8. PMID: 18397969.
- Tate AR, McClure PW, Kareha S, Irwin D. Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in overhead athletes. J Orthop Sports Phys Ther. 2008 Jan;38(1):4-11. doi: 10.2519/jospt.2008.2616. PMID: 18357656.
- Ludewig PM, Reynolds JF. The association of scapular kinematics and glenohumeral joint pathologies. J Orthop Sports Phys Ther. 2009 Feb;39(2):90-104. doi: 10.2519/jospt.2009.2808. PMID: 19194022; PMCID: PMC2730194.
- Struyf F, Nijs J, Baeyens JP, Mottram S, Meeusen R. Scapular positioning and movement in unimpaired shoulders, shoulder impingement syndrome, and glenohumeral instability. Scand J Med Sci Sports. 2011 Jun;21(3):352-8. doi: 10.1111/j.1600-0838.2010.01274.x. Epub 2011 Mar 8. PMID: 21385219.
- Watson LA, Pizzari T, Balster S. Thoracic outlet syndrome Part 2: Conservative management of thoracic outlet. Manual Therapy 15 (2010) 305e314
- Vleeming A, Schuenke MD, Masi AT, Carreiro JE, Danneels L, Willard FH. The sacroiliac joint: an overview of its anatomy, function and potential clinical implications. Journal of Anatomy. 2012;221(6):537-567. doi:10.1111/j.1469-7580.2012.01564.x.