Scapulothoracic Dyskinesis

Introduction

Abnormal scapula motion leading to shoulder impingement and dysfunction
Epidemiology
- cause are multifactorial including
  - neurologic injury
  - pathologic thoracic spine kyphosis
  - periscapular muscle fatigue
  - poor throwing mechanics
  - secondary to pain (shoulder, neck)
Pathoanatomy
- scapulothoracic power imbalance leads to protraction of scapula
  - leading to alteration of mechanics at glenohumeral joint
    - excessive stress placed on
      - anterior capsule of shoulder
      - posterosuperior labrum
    - athletes have increased risk of injuring
      - labrum
      - rotator cuff
      - capsule

Anatomy

Scapulothoracic joint anatomy

Presentation

Symptoms
- shoulder pain and dysfunction worse with arm elevation
- loss of throwing velocity
Physical exam
- scapulothoracic crepitus
- affected scapula may be lower and protracted
- symptoms relieved with scapula stabilization

Imaging

Radiographs
- usually unremarkable

Treatment

Nonoperative
- NSAIDs, PT, local injections
  - indications
    - main treatment
  - technique
    - physical therapy with emphasis on
      - core strengthening
      - scapular stabilizers, serratus anterior, trapezius
      - rotator cuff muscles
      - teaching proper core mechanics in throwers

TAG

(OBQ05.170) A 23-year-old professional pitcher complains of posterior shoulder pain. Physical exam is notable for scapular dyskinesis. No intra-articular pathology is found on shoulder MRI. Which of the following should be emphasized in the initial stages of rehabilitation? Topic

Review Topic

1. Isometric shoulder exercises
2. Isokinetic shoulder exercises
3. Closed chain shoulder exercises
4. Coordination of scapular motion with trunk and hip movements
5. Axial loading shoulder exercises

PREFERRED RESPONSE ▶

DISCUSSION: Scapular dyskinesis is an alteration in the normal motion of the scapula during coordinated scapulohumeral movements. It occurs as a sequela of prior shoulder injury, especially injuries disrupting the activation patterns of scapular stabilizing muscles. Kibler et. al outlined a rehabilitation protocol to treat scapular dyskinesis. The principle is to treat the problem from proximal to distal. The first stage involves attaining full motion of the scapula and coordinating the scapula with trunk and hip motions. Once this has been achieved, the second stage involves strengthening the scapular musculature. As scapular control is attained, exercises are introduced that place emphasis on the shoulder and arm beginning with flexibility and closed-chain strengthening, and eventually working up to sport-specific functions. Progress is determined by functional improvement rather than a strict time table. Kibler et al outline the presentation, evaluation, and treatment for scapular dyskinesis in the JAAOS review article. They specifically discuss the acute, recovery, and maintenance phases of rehabilitation.

REFERENCES:

1. Kibler WB, McMullen J, Uhl T. Shoulder rehabilitation strategies, guidelines, and practice. Orthop Clin North Am. 2001 Jul;32(3):527-38. PMID:11888148 (Link to Abstract)

2. Kibler WB, McMullen J. Scapular dyskinesis and its relation to shoulder pain. J Am Acad Orthop Surg. 2003 Mar-Apr;11(2):142-51 PMID:12670140 (Link to Abstract)

Question Authors:

John Badylak MD, Patrick McCulloch MD, Guillem Lomas MD,

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Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

Kibler WB, McMullen J, Uhl T. Shoulder rehabilitation strategies, guidelines, and practice. Orthop Clin North Am. 2001 Jul;32(3):527-38. PMID:11888148 (Link to Abstract)
Kibler WB, McMullen J. Scapular dyskinesis and its relation to shoulder pain. J Am Acad Orthop Surg. 2003 Mar-Apr;11(2):142-51 PMID:12670140 (Link to Abstract)

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