Clinical Evaluation of Scapular Dysfunction

ERIC L. SAUERS, PhD, ATC, CSCS AT. Still University

Clinical Evaluation
Ocapular dysfunction has been widely
implicated as a contributing factor to
shoulder pathology. Thus, evaluations of
scapular motion and strength have been
described as key components of a comprehensive shoulder examination. Some
methods for evaluating scapular function,
however, might not yield sufficient information from which to
make an informed clinKEY P O I N T S
ical decision regarding
Scapular evaluation should include repetiappropriate interventive loading of the scapula muscles.
tions. Traditional evaluation of the scapula
Soft-tissue mobility assessment of the
has often been limited
shoulder is an important aspect of scapular
to nothing more then
evaluation.
having patients raise
and lower their arms
Scapular special tests include the scapularfor several repetitions.
assistance test and the scapular-retraction
Unfortunately, observatest.
tion during unweighted
arm
elevation is often
Key Words: shoulder, dyskinesis, clasinsufficient to detect
sification
scapular dysfunction
because it fails to load and challenge the
scapulothoracic musculature.' Three-dimensional measurement of scapular kinematics
has provided a great deal of information
regarding normal and abnormal scapular
function, but these methods are not readily
available or practical in the clinical setting.
Determining appropriate clinical tests to
evaluate scapular dysfunction can be a
challenge. Therefore, the objective of this
article is to present methods for evaluating scapular dysfunction that will help
clinicians develop an appropriate course
of intervention.

Visualization

Evaluation of the scapula requires full visualization of the posterior thorax and both
scapulae. This can be achieved by having
male athletes remove their shirts and by
appropriately draping female athletes in
gowns tied at the neck and waist or having
them wear swimsuit tops or sport bras that
do not cover (thereby possibly stabilizing)
the scapula (Figure 1). Comprehensive evaluation of the scapula includes observation of
scapular motion to detect scapular dyskinesis
(aberrant scapular motion or winging).

I Weighted bilateral shoulder-flexion testing to

evaluate scapular motion.
Z006NumanKinetks-ATT 11(5). pp.l

10 1 SEPTEMBER 2 0 0 6

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Classification Protocols

Manual Muscle Testing

Several investigators''^ have reported on the development of scapular-assessment protocols that incorporate specific tests designed to load and challenge the
periscapular musculature in order to detect and classify movement dysfunction-Johnson et al.^ developed
a protocol that was later refined and used to evaluate
27 patients with active shoulder pathology (N = 32),'
Their data indicated that three simple clinical tests
should be performed to detect abnormal scapular
motion: (a) observation of bilateral scapular motion
during multiple repetitions (5-10) of unweighted
humeral elevation in the scapular plane to establish a
baseline of scapular movement, (b) observation of bilateral scapular motion during multiple repetitions (5-! 0)
of weighted (0.5-5 kg [I-10 lb]) shoulder flexion, and
(c) observation of scapular motion during performance
of resisted isometric external rotation with the arm at
the side in neutral rotation (scapular flip sign^). It is
important to note that an adequate amount of weight
should be chosen to load the scapular musculature but
not exacerbate shoulder pain.
Several scapular-classification protocols have
evolved from the work of Johnson et al.,^ and each
consists of similar test components that include
unweighted and weighted flexion and abduction and
the scapular flip sign.''^"*"^ Collectively these tests appear
to demonstrate acceptable intrarater' and interrater'-^'^
reliability and percentage agreement. '"'^ A positive test
for abnormal scapular motion with weighted flexion
has been shown to be a valid indicator of abnormal
scapular motion compared with three-dimensional
kinematic measures.'*
Of all of the tests reported, weighted shoulder
flexion has consistently been identified as the single
clinical test most highly associated with abnormal
scapular motion (Figure 1 ).''''^ Johnson etal.' reported
that weighted flexion and the scapular flip sign identified 100% of visible scapular-motion abnormalities.'
Gard et al.*' reported that weighted flexion identified the
most scapular-motion abnormalities (48/50), followed
by unweighted flexion (43/50). with lower values for
weighted (34/50) and unweighted abduction (29/50)
and resisted external rotation at neutral elevation
(scapular flip sign; 23/50). It is important to note that
the diagnostic value (accuracy, sensitivity, specificity,
and positive and negative predictive value) of these
tests in isolation, or as part of a classification protocol,
remains to be demonstrated.

In addition to scapular-motion assessment, a thorough

assessment of muscle strength should be performed
using graded manual muscle tests^ for the scapulastabilizing muscles including the serratus anterior,
rhomboids, and middle, upper, and lower trapezius.
These muscles are the primary scapular stabilizers,
and changes in their strength have been implicated in
altered scapular kinematics and subacromial impingement."*" Michener et al.'^ have demonstrated that a
single clinician can reliably assess these muscles using
a handiield dynamometer in patients with pain and
functional loss.

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Scapular Special Tests

The addition of scapular special tests including the
scapular-assistance test and scapular-retraction test
might prove useful in trying to determine whether
scapular-motion abnormalities are contributing to a
patient's symptoms. The scapular-assistance test is
performed by manually stabilizing the scapula on the
thorax and assisting the inferomedial border in rotating
in a stable and coordinated fashion while the patient
raises his or her arm (Figure 2),'^'"' A positive test is
when the patient reports a reduction of symptoms

I Scapular-assistance test.

SEPTEMBER 2006 I 11

while you are manually stabilizing and assisting the

scapula through a full range of motion.
The scapular-retraction test is another special test
that can be performed to assess the contribution of
the scapulothoracic articulation to impairments such
as pain and muscle weakness.'"^ The test is performed
by manual and patient-assisted retraction and stabilization of the scapula on the thorax (Figure 3). I prefer
to then have the patient move through a full range of
motion to assess any change in symptoms with manual
scapular stabilization. The scapular-retraction test has
been described as a test to assess the contribution of
scapular stability to muscle-force output. '^ The athlete
begins the test by performing a traditional empty-can
test with no scapular retraction or stabilization. The
scapula is then retracted and manually stabilized,
and the test is repeated. If the patient demonstrates
greater strength during retesting with the scapula in
the retracted and stabilized position, the test is considered positive.
The scapular-assistance and scapular-retraction
tests are both designed to stabilize and position the
scapula on the thorax. Diminished pain or increased
muscle strength during these tests suggests that abnormal scapular control is contributing to the patient's
symptoms, and rehabilitative interventions should be
implemented to restore scapular stability and motor
control. '* The diagnostic value of these tests, however,
remains to be demonstrated.

Soft-Tissue Mobility Assessment

Other useful adjuncts to clinical evaluation of the scapula include various tests of soft-tissue mobility about
the shoulder. Soft-tissue restrictions such as decreased
posterior shoulder mobility or increased pectoralisminor tightness can lead to alterations in scapular
kinematics, including reduced posterior tilting, upward
rotation, or external rotation during arm elevation.^''"'^
Posterior-capsuie or rotator-cuff tightness can be evaluated by measuring passive isolated glenohumeral-joint
internal rotation or cross-body horizontal adduction."*
Pectoraiis-minor tightness can be evaluated by measuring, with the patient supine, from the treatment
table to the posterior acromion. Wang et al.''' recently
determined that, with the patient supine on a treatment table, a linear distance between the posterior
acromion and the surface of the table of less than 2.5
cm is indicative of a short pectoralis minor.
Postural Assessment
Forward head posture, forward shoulder posture,
and thoracic kyphosis should be assessed as part of
any scapular evaluation.^'^^ Collectively, this triad of
impairments has been widely implicated in shoulder
dysfunction.^"^' Patients with spinal posture changes
indicative of forward head and shoulder posture and
thoracic kyphosis, such as increased cervical extension
and thoracic flexion, demonstrate altered scapular
kinematics consistent with subacromial impingement.^^" These postural malalignments are suspected
to inhibit scapular posterior tilt and external rotation
during arm elevation, thereby compromising the subacromial space. A quick and efficient postural screen
for forward head posture, forward shoulder posture,
and thoracic kyphosis can be accomplished using the
side-view plumb-line screen {Figure 4)."
Intervention Implications

figure 3 scapular-retraction test.

12 1 SEPTEMBER 2006

Patients with identifiable scapular impairments should

receive specific interventions to restore neuromuscular control, strength, and soft-tissue mobility and to
address postural malalignments. Treatment interventions for scapular dysfunction should be based on
specific clinical-examination findings. For instance,
two patients with subacromial-impingement syndrome
might have differing scapular contributions to their
pain and dysfunction that require different treatment
strategies. One patient might demonstrate scapular

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have been given higher priority based on the physical

examination.
Alterations in scapular kinematics in the presence
of shoulder pathology have been well demonstrated. "'^'*
Visible scapular-motion abnormalities might be more
common, however, in cases of long-standing or more
severe shoulder pathology' or in patients with nerve
injury.^^ Furthermore, the evidence suggests that visible
scapular-motion abnormalities are more prevalent in
patients with the specific diagnoses of shoulder instability and shoulder-impingement syndrome.'-^^
Proximal stability and neuromuscular control of
the scapula are critical to distal mobility and function
of the arm. A thorough and systematic evaluation of
the scapula to determine scapular-motion quantity and
quality, scapular-positioning contribution to pain and
strength, scapular-muscle strength, soft-tissue mobility,
and spinal posture should be central to every examination of the shoulder. This evaluation will help identify
specific impairments that might be contributing to
functional loss and disability and will serve to establish
clear priorities for treatment intervention. Nonetheless,
the prognostic value of scapular dysfunction in relation
to normal, pain-free shoulder function remains unclear.
More research is needed to evaluate the diagnostic and
prognostic value of scapular tests in specific patient
populations with well-defined shoulder pathology.
fiqure 4 postural assessment using the side-view plumb-line screen.

Clinical-Cvaluation Summary
dyskinesis and scapular-muscle weakness that are
leading to altered scapular kinematics (decreased
posterior tilt, external rotation, and upward rotation).
This patient would probably benefit most from a thorough scapular-stabilization and neuromuscular-control
rehabilitation program. The other patient might exhibit
coordinated and stable scapular motion but exhibit
significant pectoraiis-minor and posterior-capsule or
-cuff tightness in addition to forward shoulder posture
and thoracic kyphosis that are contributing to altered
scapular kinematics (decreased posterior tilt, external
rotation, and upward rotation). This patient would most
likely benefit from specific manual therapies aimed
at restoring soft-tissue mobility and thoracic extension coupled with strengthening exercises to promote
thoracic extension and scapular retraction. Patients
with negative scapular-examination findings should
still receive core scapular-stabilization exercises, but
these might be adjunctive to other interventions that

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1. The examiner must expose the posterior thorax

and scapulae by having male patients remove their
shirts or by draping female patients with a gown.
2. Visible observation of scapular-movement dysfunction usually requires that you repetitively challenge
the scapula under loaded conditions.
3. Clinical evaluation of the scapula should consist of
the following examination techniques:
a. Observation of bilateral scapular motion during
multiple repetitions (5-10) of unweighted shoulder flexion to determine a baseline.
b. Observation of bilateral scapular motion during
multiple repetitions (5-10) of weighted (0.5-5
kg [1-10 lb]) shoulder flexion.
c. Observation of scapular motion during performance of resisted isometric external rotation

SEPTEMBER 2006 I 13

with the arm at the side in neutral rotation

(scapular flip sign).

9. Kendall F, McCreary E, Provance P, Rodgers M, Romani W. Muscles:

Testing and Function With Posture and Pain. Baltimore, Md: Lippincott
Williams SWilkins: 2005

d. Manual muscle testing of the scapular-stabilizing muscles (serratus anterior, rhomboids, and
middle, upper, and lower trapezius).

10. LudewigPM, Cook TM. Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement. Phys Ther. 2000;80(3):276-291.

e. Performance of the manual scapular-assistance

test and scapular-retraction test to determine the
contribution of scapular dysfunction to shoulder
symptoms.
f. Evaluation of specific soft-tissue mobility patterns such as posterior-capsule or rotator-cuff
hypomobility and pectoraiis-minor tightness.
g. Screening for forward head posture, forward
shoulder posture, and thoracic kyphosis using
a side-view plumb line.
4. A thorough clinical evaluation of the scapula that
demonstrates specific impairments (e.g., dyskinesis and hypomobility) should be used to determine
specific treatment interventions (e.g., strengthening and mobilization).
5. Further research into the diagnostic and prognostic
value of clinical tests to evaluate scapular dysfunction is needed. I

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Eric Sauers is an associate professor and director of the athletic training

program, as well as chair of the Department of Interdisciplinary Health
Sciences, at Arizona School of Health Sciences, A.T. Still University,

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