Assessment and rehabilitation of scapular dyskinesis: A case study

Hariharasudhan Ravichandran; Balamurugan Janakiraman

doi:10.4103/2321-4848.196205

CASE REPORT

Year : 2016 | Volume : 4 | Issue : 2 | Page : 244-247

Assessment and rehabilitation of scapular dyskinesis: A case study

Hariharasudhan Ravichandran¹, Balamurugan Janakiraman²
¹ Orthopaedic and Sports Physiotherapist, Department of Physiotherapy, Global Hospitals and Health City, Chennai, Tamil Nadu, India
² Department of Physiotherapy, College of Medicine and Health Sciences, School of Medicine, University of Gondar, Gondar, Ethiopia

Date of Web Publication

20-Dec-2016

Correspondence Address:
Hariharasudhan Ravichandran
Department of Physiotherapy, Sree Balaji college of Physiotherapy, Chennai, Tamil Nadu
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/2321-4848.196205

Abstract

The purpose of this study was to update, discuss the accumulated knowledge regarding clinical evaluation and physical therapy rehabilitation for scapular dyskinesis. The aim of this study was to educate health professionals and athlete regarding scapular dyskinesis to make them aware of its consequences in affecting shoulder kinematics. Normal movement of scapula should not be compromised. Its deficiency results in restriction in shoulder joint functions. Mr. X, 26-year-old volleyball player with shoulder pain, was clinically assessed with scapular dyskinesis and rehabilitated through conservative physical therapy at three levels for 8 weeks. A single case study design was used to assess and rehabilitate the volleyball player with scapular dyskinesis. Scapular dyskinesis alters normal position and kinematics of scapula. Hence, it needs early diagnosis with appropriate clinical examination to rehabilitate. Physiotherapy plays a major role in it.

Keywords: Dyskinesis, rehabilitation, sick scapula syndrome

How to cite this article:
Ravichandran H, Janakiraman B. Assessment and rehabilitation of scapular dyskinesis: A case study. Arch Med Health Sci 2016;4:244-7

How to cite this URL:
Ravichandran H, Janakiraman B. Assessment and rehabilitation of scapular dyskinesis: A case study. Arch Med Health Sci [serial online] 2016 [cited 2023 Mar 29];4:244-7. Available from: https://www.amhsjournal.org/text.asp?2016/4/2/244/196205

Introduction

Scapular rehabilitation is often ignored in shoulder injuries. For the shoulder to function properly, there needs to be a balance between flexibility and stability. Anything that upsets this balance can result in an array of altered kinematics of the scapulohumeral rhythm which can lead to scapular dyskinesis. In other terms, alteration in the normal static or dynamic position or motion of the scapula during coupled scapulohumeral movements has been termed “scapular dyskinesia” (“floating scapula” or “lateral scapular slide”).^[1] Scapular dyskinesis may be found both in asymptomatic cases and in patients with pain in the shoulder girdle.^[2] Scapular dyskinesis is common among athletes playing no overhead sports or in athletes involved in several types of overhead sports, such as swimming, rugby, baseball, badminton, tennis, and volleyball, as reported in literature,^[3] as well as in cases with sequel of clavicle fractures or acromioclavicular joint injuries.^[4] There are numerous causes for scapular dyskinesis; they are postural abnormalities, muscular or capsular inflexibility, inflexibility or asymmetry in hip and trunk flexibility limiting proximal force generation in the scapula, scapular muscle fatigue, injury to the spinal accessory nerve, or long thoracic nerve or suprascapular nerve.

Burkhart et al. differentiated scapular dyskinesis into three types. They are inferomedial border scapular prominence, medial border prominence, and superomedial prominence. The overhead athlete requires full, unrestricted range of motion (ROM) of the shoulder to perform the specific skill set essential to his or her sports. The shoulder joint transfers energy generated from the lower limbs into ballistic forces of the upper limb. An epidemiological study of 372 competitive professionals and recreational athletes who performed overhead movements found that 44% experienced shoulder pain at some point during their careers.^[5]

Volleyball players are estimated to perform as many as 40,000 spikes per se ason. With this volume of action and amount of force generated in these high-powered ballistic actions, it is easy to see how the flexibility/stability balance might be disrupted, causing shoulder pathology. In this case study, we discuss the complete physical therapy rehabilitation program for a volleyball athlete with scapular dyskinesis. This case report is unique as it outlines the relevant subjective history and discusses the relevance of the objective examination. Then, the analysis behind the rationale for the clinical diagnosis is reviewed. This is followed by a brief outline of the physical therapy rehabilitation, followed by the treatment progression and an explanation on the effectiveness of the rehabilitation.

Case Report

Mr. X, a 26-year-old state-level volleyball player, was referred to our clinic with complaints of progressive worsening of pain in the right shoulder, for the past 1 month, with no significant traumatic or pathological history. Pain in the shoulder was exacerbated while serving and spiking the ball. The onset of pain is gradual and progressive over a period. He is a right-handed individual. He had no swelling or tropical changes in the skin. There was no history of trauma or injury or inciting event associated with this pain. He had no history of neck pain or radiating pain or numbness in the upper limbs. He feels weakness of right arm which is more evident while serving the ball; furthermore, the velocity of the serving ball has been diminished. At initial stages of pain, he was advised to take rest for 1 week with analgesics, cryotherapy, and ultrasound therapy for a week; however, there is no significant improvement in pain relief. He was out of the match practice for 2 weeks and not participated even in fitness activities. He was advised to undergo radiograph of the right shoulder and the reports were normal. Hence, he underwent magnetic resonance imaging (MRI) of shoulder, which revealed no abnormal diagnosis. With this present medical history we assessed him. On observation, there is no swelling or ecchymosis in the shoulder. Bony contours are same bilaterally. From anterior view, right-sided shoulder is drooped and not in level with the left shoulder. There is no sulcus sign. From posterior view, right scapular prominence increased at the inferomedial angle. Mr. X was asked to elevate his arm in flexion and abduction, and it was noticed that there are irregular hitches and jumps in scapular motion during arm movement. Tenderness was present at the medial border of the corocoid process of the right scapula suggestive of tightness of pectoralis minor. His ROM was full in all planes exception for pain-limited abduction to 130° and flexion to 150°. All the fibers of deltoid, biceps, triceps, lower trapezius, and serratus anterior on his right shoulder were 4/5, which is weaker than the left side of those respective muscles 5/5. He had no power deficits around elbow, wrist, and finger regions bilaterally. Pectoralis minor length test was done bilaterally, and it showed that he had tightness on the right side. His dermatomes and myotomes were all within the normal limits bilaterally. His distal pulses were felt bilaterally. In scapular isometric pinch or squeeze test,^[6] he was made to stand and asked to actively retract both the scapula together as hard as possible and to hold the position for as long as possible. He complained of difficulty in holding due to pain in the right scapular region within 7 s. This indicates the weakness of scapular retractors. In scapular reposition test,^[7] there is increased strength of supraspinatus and reduction in pain on the right side than the baseline recordings which depict that this test is positive. Scapular assistance test ^[8] was performed by recording his baseline active ROM and pain, and then he was asked to elevate his arm in forward flexion and therapist applied manual assistance by pushing the scapula laterally and upward on the inferior medial border of scapula to simulate serratus anterior and lower trapezius activity. His ROM increased simultaneously with reduction of pain. Hence, this test is positive. AC joint shear test, shoulder instability test, Yergason's test,^[9] Codman's drop arm test,^[9] and Empty Can test ^[9] are all negative. We studied the shoulder radiograph and MRI images of Mr. X, which revealed no abnormal bony, joint, or soft tissue pathologies. The diagnosis of Mr. X's injury is right shoulder dyskinesis falling under Type I inferomedial prominence or scapula. Scapular dyskinesis is diagnosed primarily on the history and physical examination. Our clinical findings were pectoralis minor tightness, weakness of serratus anterior and lower trapezius, and irregular movement of scapula with overhead arm movements.

Mr. X was educated about dyskinesia and the rehabilitation program he has to undergo. Before the rehabilitation, his visual analog scale (VAS) score was 7/10 during activities of the upper limb and 5/10 while at rest. In the first week of rehabilitation, we focused on improving conscious muscle control of the scapula to normalize resting position of the scapula. He was advised to avoid right arm elevation above 90° and excessive protrusion of the shoulder. He was advised to maintain correct posture of the shoulder during his daily activities. For pain management, cryotherapy was advised. He performed stretching of pectoralis minor, posterior capsule, upper trapezius, and levator scapulae before beginning any exercise program. Closed kinetic chain exercises were taught to stimulate co-contraction of the rotator cuff and scapular musculatures to promote scapulohumeral control and glenohumeral joint stability. These exercises were scapular clock exercise at 12, 3, and 9 O'clock positions, closed chain strengthening exercise for scapular protraction and retraction using physioball, weight-bearing isometric extension exercise, and upper extremity weight shifts. Gradually, in the next phase, he was started on open kinetic exercises (3 weeks duration) including, prone lying scapular retraction, prone lying horizontal extension of shoulder, prone lying shoulder extension, and prone lying shoulder flexion. Active shoulder rotation of internal and external rotation was advised with 0° of shoulder abduction. Mr. X was advised to do scapular movement facilitation exercises using trunk movement; trunk extension with lateral rotation facilitates scapular retraction; trunk flexion with medial rotation facilitates scapular protraction. Taping applied to prevent shoulder protraction. Kinesio Taping was applied with a goal to improve proprioception and trunk posture while glenohumeral movement takes place.^[10] In our earlier assessment, Mr. X was found to have serratus anterior and lower trapezius weakness, for which muscle energy technique of postisometric relaxation was done for serratus anterior, and lower trapezius was done at a frequency of ten repetitions per se ssion, two sessions per day. Core stabilization exercises were advised to establish good thoracic posture. These include curl-ups, hip extensor exercises in prone and standing. Mr. X was reassessed after 4 weeks and found to have VAS score of 4/10 during activities and 1/10 (occasionally) at rest. Furthermore, arm elevation above 130° was painless in both flexion and abduction. We increased closed kinetic chain workouts; Mr. X was taught wall push-ups, table push-ups, modified prone push-ups, and single-leg squats. We taught him strengthening of rotator cuff from isometric to concentric, and at the end of the 5^th week, eccentric exercises were initiated. In the advanced stage (2 weeks), the goal is to improve neuromuscular control. Proprioceptive neuromuscular facilitation (PNF) exercises help enhance neuromuscular control. PNF pattern of flexion – abduction – external rotation and extension – abduction – internal rotation was trained. TheraBand resistance exercises were advised with emphasis on the eccentric phase of motion. To achieve this, Mr. X was advised to do scapular retraction with trunk and hip extension during protraction with trunk and hip flexion. We advised core strengthening; he was asked to continue curl-ups, prone hip extension exercises along with abdominal crunches. All these exercises were done at a frequency of two sessions a day.

Results

After 6 weeks, we reassessed him and found that he is pain-free throughout the full ROM, reduction in tightness of pectoralis minor, and achieved good scapular control. Sports-specific strengthening was our goal now. Hence, Mr. X was advised to perform medicine ball exercises, plyometrics, dumbbells punch and overhead dumbbell press, and lunge reach exercises. He was assessed and found to be clinically fit. He was comfortable without pain during the volleyball serve and cleared his fitness test successfully and started to practice for volleyball match after 6 weeks.

Discussion

In the dyskinesis management program, Mr. X was approached to rehabilitate the scapula from a proximal to distal perspective. It uses muscle activation pattern to achieve this objective by facilitation through the complimentary trunk and hip movement. Lower extremity and trunk activation establishes the normal kinetic chain sequences that yield the desired scapular motion. In rehabilitation of scapular dyskinesis, therapeutic exercises must focus on restoring alignment and muscular control of the scapulothoracic region. Once scapular motion is normalized, these kinetic chain movement patterns are the framework for exercises to strengthen the scapular musculatures. Furthermore, closed and open kinetic chain exercises are used to correct the abnormal firing patterns of scapular stabilizers as it relates to the upper, middle, and lower fibers of trapezius, serratus anterior, and rhomboids. In the beginning of rehabilitation, the goal is to achieve an active control on scapular reposition and orientation to enhance muscle flexibility. In the second phase of our rehabilitation, we focused more on closed chain exercises, which are believed to improve dynamic glenohumeral stability through stimulation of the intra-articular and periarticular proprioceptors and enhance co-contraction of the rotator cuff, thus being beneficial in dyskinesia. According to Uhl et al., closed chain training is also very useful when patients have difficulties fixating the scapula to the chest wall.^[11] In the advanced stage of scapular rehabilitation, in which the treatment goal is to improve scapular muscle control and strength during sport-specific movements, plyometric exercises are beneficial. This fact was correlated with the findings of Ellenbecker and Cools and Carter et al.^[12],[13] Lower trapezius activation was improved with PNF technique. Youdas et al. studied muscle activation while performing PNF using electromyography and their study results showed that lower trapezius activation was greater in D2F pattern of PNF technique.^[14] Kinesio Taping improved scapular motion and muscle performance; this was supported by the study results of Hsu et al.^[15] Early recognition of this condition and management through physical therapy means of rehabilitation were found to be effective in avoiding the risk factors such as glenohumeral internal derangement, superior labrum tears, and rotator cuff injuries.

Conclusion

The shoulder joint is a complex part that is commonly injured in overhead throwing or pitching athletes. The key to accurate diagnosis is a thorough history, physical examination, and ruling out the other conditions that mimic the clinical presentation, for which sound knowledge in the anatomy, biomechanics, and pathomechanics is essential. Even though accurate diagnosis alone is not sufficient, success in clinical practice is achieved with the optimal level of rehabilitation provided and returning the athlete to his/her sports career at the earliest possible. The focus on scapula in shoulder rehabilitation is to establish normal function rather than to alleviate symptoms. The difference between an athlete and nonathlete in rehabilitation is 100% fitness, which is essential for an athlete to return to his/her sports career. Even 1% compromise in an athlete's fitness compromises the nation from performing the best from his/her part. Hence, a physical therapist with sound knowledge, hypothetical view in evaluation, providing current evidence-based practice in rehabilitation delivers 100% in the clinical practice. In summary, this case study delivered all the methods of clinical assessment and provided the efficient rehabilitation methods in scapular dyskinesis for Mr. X.

Acknowledgment

We thank Dr. S. S. Subramanian for the efforts made to carry out this case study and all staffs of Sree Balaji college of Physiotherapy for providing the rehabilitation set up.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Kibler WB, McMullen J. Scapular dyskinesis and its relation to shoulder pain. J Am Acad Orthop Surg 2003;11:142-51.
2.	Juul-Kristensen B, Hilt K, Enoch F, Remvig L, Sjøgaard G. Scapular dyskinesis in trapezius myalgia and intraexaminer reproducibility of clinical tests. Physiother Theory Pract 2011;27:492-502.
3.	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;44:407-10.
4.	Gumina S, Carbone S, Postacchini F. Scapular dyskinesis and SICK scapula syndrome in patients with chronic type III acromioclavicular dislocation. Arthroscopy 2009;25:40-5.
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;19:641-61.
6.	Kibler WB. Evaluation and diagnosis of scapulothoracic problems in the athlete. Sports Med Arthrosc Rev 2000;8:192-202.
7.	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;38:4-11.
8.	Rabin A, Irrgang JJ, Fitzgerald GK, Eubanks A. The intertester reliability of the Scapular Assistance Test. J Orthop Sports Phys Ther 2006;36:653-60.
9.	Magee DJ. Orthopaedic Physical Assessment. 3^rd ed. Philadelphia, PA: WB Saunders; 1997.
10.	Lewis JS, Wright C, Green A. Subacromial impingement syndrome: The effect of changing posture on shoulder range of movement. J Orthop Sports Phys Ther 2005;35:72-87.
11.	Uhl TL, Carver TJ, Mattacola CG, Mair SD, Nitz AJ. Shoulder musculature activation during upper extremity weight-bearing exercise. J Orthop Sports Phys Ther 2003;33:109-17.
12.	Ellenbecker TS, Cools A. Rehabilitation of shoulder impingement syndrome and rotator cuff injuries: An evidence-based review. Br J Sports Med 2010;44:319-27.
13.	Carter AB, Kaminski TW, Douex AT Jr., Knight CA, Richards JG. Effects of high volume upper extremity plyometric training on throwing velocity and functional strength ratios of the shoulder rotators in collegiate baseball players. J Strength Cond Res 2007;21:208-15.
14.	Youdas JW, Arend DB, Exstrom JM, Helmus TJ, Rozeboom JD, Hollman JH. Comparison of muscle activation levels during arm abduction in the plane of the scapula vs. proprioceptive neuromuscular facilitation upper extremity patterns. J Strength Cond Res 2012;26:1058-65.
15.	Hsu YH, Chen WY, Lin HC, Wang WT, Shih YF. The effects of taping on scapular kinematics and muscle performance in baseball players with shoulder impingement syndrome. J Electromyogr Kinesiol 2009;19:1092-9.