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Case Report

Assessment and Rehabilitation of Scapular Dyskinesis: A Case


Study
Hariharasudhan Ravichandran, Balamurugan Janakiraman1
Orthopaedic and Sports Physiotherapist, Department of Physiotherapy, Global Hospitals and Health City, Chennai, Tamil Nadu, India, 1Department of Physiotherapy,
College of Medicine and Health Sciences, School of Medicine, University of Gondar, Gondar, Ethiopia

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.

Key words: Dyskinesis, rehabilitation, sick scapula syndrome

Introduction Burkhart et al. differentiated scapular dyskinesis into three


types. They are inferomedial border scapular prominence,
Scapular rehabilitation is often ignored in shoulder injuries.
medial border prominence, and superomedial prominence.
For the shoulder to function properly, there needs to be a
The overhead athlete requires full, unrestricted range of
balance between flexibility and stability. Anything that upsets
motion (ROM) of the shoulder to perform the specific skill
this balance can result in an array of altered kinematics
set essential to his or her sports. The shoulder joint transfers
of the scapulohumeral rhythm which can lead to scapular
energy generated from the lower limbs into ballistic forces of
dyskinesis. In other terms, alteration in the normal static or
the upper limb. An epidemiological study of 372 competitive
dynamic position or motion of the scapula during coupled
professionals and recreational athletes who performed
scapulohumeral movements has been termed “scapular
overhead movements found that 44% experienced shoulder
dyskinesia” (“floating scapula” or “lateral scapular slide”).[1]
pain at some point during their careers.[5]
Scapular dyskinesis may be found both in asymptomatic cases
and in patients with pain in the shoulder girdle.[2] Scapular Volleyball players are estimated to perform as many as 40,000
dyskinesis is common among athletes playing no overhead spikes per season. With this volume of action and amount of
sports or in athletes involved in several types of overhead force generated in these high‑powered ballistic actions, it
sports, such as swimming, rugby, baseball, badminton, tennis, is easy to see how the flexibility/stability balance might be
and volleyball, as reported in literature,[3] as well as in cases disrupted, causing shoulder pathology. In this case study, we
with sequel of clavicle fractures or acromioclavicular joint discuss the complete physical therapy rehabilitation program
injuries.[4] There are numerous causes for scapular dyskinesis;
they are postural abnormalities, muscular or capsular
Address for correspondence: Dr. Hariharasudhan Ravichandran,
inflexibility, inflexibility or asymmetry in hip and trunk Department of Physiotherapy, Sree Balaji college of
flexibility limiting proximal force generation in the scapula, Physiotherapy, Chennai, Tamil Nadu, India.
scapular muscle fatigue, injury to the spinal accessory nerve, E‑Mail: hrkums63@gmail.com
or long thoracic nerve or suprascapular nerve.
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DOI: How to cite this article: Ravichandran H, Janakiraman B. Assessment


10.4103/2321-4848.196205 and rehabilitation of scapular dyskinesis: A case study. Arch Med Health
Sci 2016;4:244-7.

244 © 2016 Archives of Medicine and Health Sciences | Published by Wolters Kluwer - Medknow
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Ravichandran and Janakiraman: Case Study on Scapular Dyskinesis

for a volleyball athlete with scapular dyskinesis. This case there is increased strength of supraspinatus and reduction
report is unique as it outlines the relevant subjective history in pain on the right side than the baseline recordings which
and discusses the relevance of the objective examination. Then, depict that this test is positive. Scapular assistance test[8] was
the analysis behind the rationale for the clinical diagnosis is performed by recording his baseline active ROM and pain,
reviewed. This is followed by a brief outline of the physical and then he was asked to elevate his arm in forward flexion
therapy rehabilitation, followed by the treatment progression and therapist applied manual assistance by pushing the scapula
and an explanation on the effectiveness of the rehabilitation. laterally and upward on the inferior medial border of scapula
to simulate serratus anterior and lower trapezius activity. His
Case Report ROM increased simultaneously with reduction of pain. Hence,
this test is positive. AC joint shear test, shoulder instability
Mr. X, a 26‑year‑old state‑level volleyball player, was referred
test, Yergason’s test,[9] Codman’s drop arm test,[9] and Empty
to our clinic with complaints of progressive worsening of
Can test[9] are all negative. We studied the shoulder radiograph
pain in the right shoulder, for the past 1 month, with no
and MRI images of Mr. X, which revealed no abnormal bony,
significant traumatic or pathological history. Pain in the
joint, or soft tissue pathologies. The diagnosis of Mr. X’s injury
shoulder was exacerbated while serving and spiking the ball.
is right shoulder dyskinesis falling under Type I inferomedial
The onset of pain is gradual and progressive over a period. He
prominence or scapula. Scapular dyskinesis is diagnosed
is a right‑handed individual. He had no swelling or tropical
primarily on the history and physical examination. Our clinical
changes in the skin. There was no history of trauma or injury
findings were pectoralis minor tightness, weakness of serratus
or inciting event associated with this pain. He had no history
anterior and lower trapezius, and irregular movement of
of neck pain or radiating pain or numbness in the upper limbs.
scapula with overhead arm movements.
He feels weakness of right arm which is more evident while
serving the ball; furthermore, the velocity of the serving ball Mr. X was educated about dyskinesia and the rehabilitation
has been diminished. At initial stages of pain, he was advised program he has to undergo. Before the rehabilitation, his
to take rest for 1 week with analgesics, cryotherapy, and visual analog scale (VAS) score was 7/10 during activities
ultrasound therapy for a week; however, there is no significant of the upper limb and 5/10 while at rest. In the first week of
improvement in pain relief. He was out of the match practice rehabilitation, we focused on improving conscious muscle
for 2 weeks and not participated even in fitness activities. He control of the scapula to normalize resting position of the
was advised to undergo radiograph of the right shoulder and the scapula. He was advised to avoid right arm elevation above
reports were normal. Hence, he underwent magnetic resonance 90° and excessive protrusion of the shoulder. He was advised
imaging (MRI) of shoulder, which revealed no abnormal to maintain correct posture of the shoulder during his daily
diagnosis. With this present medical history we assessed him. activities. For pain management, cryotherapy was advised. He
On observation, there is no swelling or ecchymosis in the performed stretching of pectoralis minor, posterior capsule,
shoulder. Bony contours are same bilaterally. From anterior upper trapezius, and levator scapulae before beginning
view, right‑sided shoulder is drooped and not in level with the any exercise program. Closed kinetic chain exercises were
left shoulder. There is no sulcus sign. From posterior view, taught to stimulate co‑contraction of the rotator cuff and
right scapular prominence increased at the inferomedial angle. scapular musculatures to promote scapulohumeral control and
Mr. X was asked to elevate his arm in flexion and abduction, glenohumeral joint stability. These exercises were scapular
and it was noticed that there are irregular hitches and jumps clock exercise at 12, 3, and 9 O’clock positions, closed chain
in scapular motion during arm movement. Tenderness was strengthening exercise for scapular protraction and retraction
present at the medial border of the corocoid process of the right using physioball, weight‑bearing isometric extension exercise,
scapula suggestive of tightness of pectoralis minor. His ROM and upper extremity weight shifts. Gradually, in the next
was full in all planes exception for pain‑limited abduction phase, he was started on open kinetic exercises (3 weeks
to 130° and flexion to 150°. All the fibers of deltoid, biceps, duration) including, prone lying scapular retraction, prone
triceps, lower trapezius, and serratus anterior on his right lying horizontal extension of shoulder, prone lying shoulder
shoulder were 4/5, which is weaker than the left side of those extension, and prone lying shoulder flexion. Active shoulder
respective muscles 5/5. He had no power deficits around elbow, rotation of internal and external rotation was advised with
wrist, and finger regions bilaterally. Pectoralis minor length 0° of shoulder abduction. Mr. X was advised to do scapular
test was done bilaterally, and it showed that he had tightness movement facilitation exercises using trunk movement;
on the right side. His dermatomes and myotomes were all trunk extension with lateral rotation facilitates scapular
within the normal limits bilaterally. His distal pulses were felt retraction; trunk flexion with medial rotation facilitates
bilaterally. In scapular isometric pinch or squeeze test,[6] he was scapular protraction. Taping applied to prevent shoulder
made to stand and asked to actively retract both the scapula protraction. Kinesio Taping was applied with a goal to
together as hard as possible and to hold the position for as improve proprioception and trunk posture while glenohumeral
long as possible. He complained of difficulty in holding due to movement takes place.[10] In our earlier assessment, Mr. X was
pain in the right scapular region within 7 s. This indicates the found to have serratus anterior and lower trapezius weakness,
weakness of scapular retractors. In scapular reposition test,[7] for which muscle energy technique of postisometric relaxation

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Ravichandran and Janakiraman: Case Study on Scapular Dyskinesis

was done for serratus anterior, and lower trapezius was done the goal is to achieve an active control on scapular
at a frequency of ten repetitions per session, two sessions per reposition and orientation to enhance muscle flexibility. In
day. Core stabilization exercises were advised to establish good the second phase of our rehabilitation, we focused more
thoracic posture. These include curl‑ups, hip extensor exercises on closed chain exercises, which are believed to improve
in prone and standing. Mr. X was reassessed after 4 weeks and dynamic glenohumeral stability through stimulation of the
found to have VAS score of 4/10 during activities and 1/10 intra‑articular and periarticular proprioceptors and enhance
(occasionally) at rest. Furthermore, arm elevation above 130° co‑contraction of the rotator cuff, thus being beneficial in
was painless in both flexion and abduction. We increased closed dyskinesia. According to Uhl et al., closed chain training is
kinetic chain workouts; Mr. X was taught wall push‑ups, table also very useful when patients have difficulties fixating the
push‑ups, modified prone push‑ups, and single‑leg squats. scapula to the chest wall.[11] In the advanced stage of scapular
We taught him strengthening of rotator cuff from isometric to rehabilitation, in which the treatment goal is to improve
concentric, and at the end of the 5th week, eccentric exercises scapular muscle control and strength during sport‑specific
were initiated. In the advanced stage (2 weeks), the goal is to movements, plyometric exercises are beneficial. This fact
improve neuromuscular control. Proprioceptive neuromuscular was correlated with the findings of Ellenbecker and Cools
facilitation (PNF) exercises help enhance neuromuscular and Carter et al.[12,13] Lower trapezius activation was improved
control. PNF pattern of flexion – abduction – external rotation with PNF technique. Youdas et al. studied muscle activation
and extension – abduction – internal rotation was trained. while performing PNF using electromyography and their
TheraBand resistance exercises were advised with emphasis study results showed that lower trapezius activation was
on the eccentric phase of motion. To achieve this, Mr. X was greater in D2F pattern of PNF technique.[14] Kinesio Taping
advised to do scapular retraction with trunk and hip extension improved scapular motion and muscle performance; this
during protraction with trunk and hip flexion. We advised core was supported by the study results of Hsu et al.[15] Early
strengthening; he was asked to continue curl‑ups, prone hip recognition of this condition and management through
extension exercises along with abdominal crunches. All these physical therapy means of rehabilitation were found to be
exercises were done at a frequency of two sessions a day. effective in avoiding the risk factors such as glenohumeral
internal derangement, superior labrum tears, and rotator cuff
Results injuries.
After 6 weeks, we reassessed him and found that he is pain‑free
throughout the full ROM, reduction in tightness of pectoralis Conclusion
minor, and achieved good scapular control. Sports‑specific The shoulder joint is a complex part that is commonly
strengthening was our goal now. Hence, Mr. X was advised to injured in overhead throwing or pitching athletes. The key to
perform medicine ball exercises, plyometrics, dumbbells punch accurate diagnosis is a thorough history, physical examination,
and overhead dumbbell press, and lunge reach exercises. He and ruling out the other conditions that mimic the clinical
was assessed and found to be clinically fit. He was comfortable presentation, for which sound knowledge in the anatomy,
without pain during the volleyball serve and cleared his fitness biomechanics, and pathomechanics is essential. Even though
test successfully and started to practice for volleyball match accurate diagnosis alone is not sufficient, success in clinical
after 6 weeks. practice is achieved with the optimal level of rehabilitation
provided and returning the athlete to his/her sports career
Discussion at the earliest possible. The focus on scapula in shoulder
rehabilitation is to establish normal function rather than
In the dyskinesis management program, Mr. X was to alleviate symptoms. The difference between an athlete
approached to rehabilitate the scapula from a proximal to and nonathlete in rehabilitation is 100% fitness, which is
distal perspective. It uses muscle activation pattern to achieve essential for an athlete to return to his/her sports career.
this objective by facilitation through the complimentary trunk Even 1% compromise in an athlete’s fitness compromises the
and hip movement. Lower extremity and trunk activation nation from performing the best from his/her part. Hence, a
establishes the normal kinetic chain sequences that yield physical therapist with sound knowledge, hypothetical view
the desired scapular motion. In rehabilitation of scapular in evaluation, providing current evidence‑based practice
dyskinesis, therapeutic exercises must focus on restoring in rehabilitation delivers 100% in the clinical practice. In
alignment and muscular control of the scapulothoracic summary, this case study delivered all the methods of clinical
region. Once scapular motion is normalized, these kinetic assessment and provided the efficient rehabilitation methods
chain movement patterns are the framework for exercises to in scapular dyskinesis for Mr. X.
strengthen the scapular musculatures. Furthermore, closed
and open kinetic chain exercises are used to correct the Acknowledgment
abnormal firing patterns of scapular stabilizers as it relates We thank Dr. S. S. Subramanian for the efforts made to carry
to the upper, middle, and lower fibers of trapezius, serratus out this case study and all staffs of Sree Balaji college of
anterior, and rhomboids. In the beginning of rehabilitation, Physiotherapy for providing the rehabilitation set up.

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Nil. reliability of the Scapular Assistance Test. J Orthop Sports Phys Ther
2006;36:653‑60.
Conflicts of interest 9. Magee DJ. Orthopaedic Physical Assessment. 3rd ed. Philadelphia, PA:
There are no conflicts of interest. 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
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