Clinical Evaluation of Scapular DysfunctionERIC L. SAUERS, PhD, ATC, CSCS AT. Still University

Ocapular dysfunction has been widelyimplicated as a contributing factor toshoulder pathology. Thus, evaluations ofscapular motion and strength have beendescribed as key components of a com-prehensive shoulder examination. Somemethods for evaluating scapular function,however, might not yield sufficient infor-

mation from which tomake an informed clin-ical decision regardingappropriate interven-tions. Traditional evalu-ation of the scapulahas often been limitedto nothing more thenhaving patients raiseand lower their armsfor several repetitions.Unfortunately, observa-tion during unweightedarm elevation is ofteninsufficient to detectscapular dysfunction

because it fails to load and challenge thescapulothoracic musculature.' Three-dimen-sional measurement of scapular kinematicshas provided a great deal of informationregarding normal and abnormal scapularfunction, but these methods are not readilyavailable or practical in the clinical setting.Determining appropriate clinical tests toevaluate scapular dysfunction can be achallenge. Therefore, the objective of thisarticle is to present methods for evaluat-ing scapular dysfunction that will helpclinicians develop an appropriate courseof intervention.

KEY POINTSScapular evaluation should include repeti-tive loading of the scapula muscles.

Soft-tissue mobility assessment of theshoulder is an important aspect of scapularevaluation.

Scapular special tests include the scapular-assistance test and the scapular-retractiontest.

Key Words: shoulder, dyskinesis, clas-sification

Clinical EvaluationVisualization

Evaluation of the scapula requires full visu-alization of the posterior thorax and bothscapulae. This can be achieved by havingmale athletes remove their shirts and byappropriately draping female athletes ingowns tied at the neck and waist or havingthem wear swimsuit tops or sport bras thatdo not cover (thereby possibly stabilizing)the scapula (Figure 1). Comprehensive evalu-ation of the scapula includes observation ofscapular motion to detect scapular dyskinesis(aberrant scapular motion or winging).

I Weighted bilateral shoulder-flexion testing toevaluate scapular motion.

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Classification Protocols Manual Muscle TestingSeveral investigators''^ have reported on the develop-ment of scapular-assessment protocols that incorpo-rate specific tests designed to load and challenge theperiscapular musculature in order to detect and clas-sify movement dysfunction-Johnson et al.^ developeda protocol that was later refined and used to evaluate27 patients with active shoulder pathology (N = 32),'Their data indicated that three simple clinical testsshould be performed to detect abnormal scapularmotion: (a) observation of bilateral scapular motionduring multiple repetitions (5-10) of unweightedhumeral elevation in the scapular plane to establish abaseline of scapular movement, (b) observation of bilat-eral 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 performanceof resisted isometric external rotation with the arm atthe side in neutral rotation (scapular flip sign^). It isimportant to note that an adequate amount of weightshould be chosen to load the scapular musculature butnot exacerbate shoulder pain.

Several scapular-classification protocols haveevolved from the work of Johnson et al.,^ and eachconsists of similar test components that includeunweighted and weighted flexion and abduction andthe scapular flip sign.''^ "*"^ Collectively these tests appearto demonstrate acceptable intrarater' and interrater'- '^^reliability and percentage agreement. '"'^ A positive testfor abnormal scapular motion with weighted flexionhas been shown to be a valid indicator of abnormalscapular motion compared with three-dimensionalkinematic measures.'*

Of all of the tests reported, weighted shoulderflexion has consistently been identified as the singleclinical test most highly associated with abnormalscapular motion (Figure 1 ).''''^ Johnson etal.' reportedthat weighted flexion and the scapular flip sign identi-fied 100% of visible scapular-motion abnormalities.'Gard et al.*' reported that weighted flexion identified themost scapular-motion abnormalities (48/50), followedby unweighted flexion (43/50). with lower values forweighted (34/50) and unweighted abduction (29/50)and resisted external rotation at neutral elevation(scapular flip sign; 23/50). It is important to note thatthe diagnostic value (accuracy, sensitivity, specificity,and positive and negative predictive value) of thesetests in isolation, or as part of a classification protocol,remains to be demonstrated.

In addition to scapular-motion assessment, a thoroughassessment of muscle strength should be performedusing graded manual muscle tests^ for the scapula-stabilizing 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 inaltered scapular kinematics and subacromial impinge-ment."*" Michener et al.'^ have demonstrated that asingle clinician can reliably assess these muscles usinga handiield dynamometer in patients with pain andfunctional loss.

Scapular Special TestsThe addition of scapular special tests including thescapular-assistance test and scapular-retraction testmight prove useful in trying to determine whetherscapular-motion abnormalities are contributing to apatient's symptoms. The scapular-assistance test isperformed by manually stabilizing the scapula on thethorax and assisting the inferomedial border in rotatingin a stable and coordinated fashion while the patientraises his or her arm (Figure 2),'^'"' A positive test iswhen the patient reports a reduction of symptoms

I Scapular-assistance test.

ATHLETIC THERAPY TODAY SEPTEMBER 2006 I 11

while you are manually stabilizing and assisting thescapula through a full range of motion.

The scapular-retraction test is another special testthat can be performed to assess the contribution ofthe scapulothoracic articulation to impairments suchas pain and muscle weakness.'"^ The test is performedby manual and patient-assisted retraction and stabili-zation of the scapula on the thorax (Figure 3). I preferto then have the patient move through a full range ofmotion to assess any change in symptoms with manualscapular stabilization. The scapular-retraction test hasbeen described as a test to assess the contribution ofscapular stability to muscle-force output. '^ The athletebegins the test by performing a traditional empty-cantest with no scapular retraction or stabilization. Thescapula is then retracted and manually stabilized,and the test is repeated. If the patient demonstratesgreater strength during retesting with the scapula inthe retracted and stabilized position, the test is con-sidered positive.

The scapular-assistance and scapular-retractiontests are both designed to stabilize and position thescapula on the thorax. Diminished pain or increasedmuscle strength during these tests suggests that abnor-mal scapular control is contributing to the patient'ssymptoms, and rehabilitative interventions should beimplemented to restore scapular stability and motorcontrol. '* The diagnostic value of these tests, however,remains to be demonstrated.

figure 3 scapular-retraction test.

Soft-Tissue Mobility AssessmentOther useful adjuncts to clinical evaluation of the scap-ula include various tests of soft-tissue mobility aboutthe shoulder. Soft-tissue restrictions such as decreasedposterior shoulder mobility or increased pectoralis-minor tightness can lead to alterations in scapularkinematics, including reduced posterior tilting, upwardrotation, or external rotation during arm elevation.^''"'^Posterior-capsuie or rotator-cuff tightness can be evalu-ated by measuring passive isolated glenohumeral-jointinternal rotation or cross-body horizontal adduction."*Pectoraiis-minor tightness can be evaluated by mea-suring, with the patient supine, from the treatmenttable to the posterior acromion. Wang et al.''' recentlydetermined that, with the patient supine on a treat-ment table, a linear distance between the posterioracromion and the surface of the table of less than 2.5cm is indicative of a short pectoralis minor.

Postural AssessmentForward head posture, forward shoulder posture,and thoracic kyphosis should be assessed as part ofany scapular evaluation.^ '^ ^ Collectively, this triad ofimpairments has been widely implicated in shoulderdysfunction.^ " '^ Patients with spinal posture changesindicative of forward head and shoulder posture andthoracic kyphosis, such as increased cervical extensionand thoracic flexion, demonstrate altered scapularkinematics consistent with subacromial impinge-ment.^^" These postural malalignments are suspectedto inhibit scapular posterior tilt and external rotationduring arm elevation, thereby compromising the sub-acromial space. A quick and efficient postural screenfor forward head posture, forward shoulder posture,and thoracic kyphosis can be accomplished using theside-view plumb-line screen {Figure 4)."

Intervention ImplicationsPatients with identifiable scapular impairments shouldreceive specific interventions to restore neuromuscu-lar control, strength, and soft-tissue mobility and toaddress postural malalignments. Treatment interven-tions for scapular dysfunction should be based onspecific clinical-examination findings. For instance,two patients with subacromial-impingement syndromemight have differing scapular contributions to theirpain and dysfunction that require different treatmentstrategies. One patient might demonstrate scapular

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fiqure 4 postural assessment using the side-view plumb-line screen.

dyskinesis and scapular-muscle weakness that areleading to altered scapular kinematics (decreasedposterior tilt, external rotation, and upward rotation).This patient would probably benefit most from a thor-ough scapular-stabilization and neuromuscular-controlrehabilitation program. The other patient might exhibitcoordinated and stable scapular motion but exhibitsignificant pectoraiis-minor and posterior-capsule or-cuff tightness in addition to forward shoulder postureand thoracic kyphosis that are contributing to alteredscapular kinematics (decreased posterior tilt, externalrotation, and upward rotation). This patient would mostlikely benefit from specific manual therapies aimedat restoring soft-tissue mobility and thoracic exten-sion coupled with strengthening exercises to promotethoracic extension and scapular retraction. Patientswith negative scapular-examination findings shouldstill receive core scapular-stabilization exercises, butthese might be adjunctive to other interventions that

have been given higher priority based on the physicalexamination.

Alterations in scapular kinematics in the presenceof shoulder pathology have been well demonstrated. "'^ '*Visible scapular-motion abnormalities might be morecommon, however, in cases of long-standing or moresevere shoulder pathology' or in patients with nerveinjury.^ ^ Furthermore, the evidence suggests that visiblescapular-motion abnormalities are more prevalent inpatients with the specific diagnoses of shoulder insta-bility and shoulder-impingement syndrome.'-^^

Proximal stability and neuromuscular control ofthe scapula are critical to distal mobility and functionof the arm. A thorough and systematic evaluation ofthe scapula to determine scapular-motion quantity andquality, scapular-positioning contribution to pain andstrength, scapular-muscle strength, soft-tissue mobility,and spinal posture should be central to every examina-tion of the shoulder. This evaluation will help identifyspecific impairments that might be contributing tofunctional loss and disability and will serve to establishclear priorities for treatment intervention. Nonetheless,the prognostic value of scapular dysfunction in relationto normal, pain-free shoulder function remains unclear.More research is needed to evaluate the diagnostic andprognostic value of scapular tests in specific patientpopulations with well-defined shoulder pathology.

Clinical-Cvaluation Summary

1. The examiner must expose the posterior thoraxand scapulae by having male patients remove theirshirts or by draping female patients with a gown.

2. Visible observation of scapular-movement dysfunc-tion usually requires that you repetitively challengethe scapula under loaded conditions.

3. Clinical evaluation of the scapula should consist ofthe following examination techniques:

a. Observation of bilateral scapular motion duringmultiple repetitions (5-10) of unweighted shoul-der flexion to determine a baseline.

b. Observation of bilateral scapular motion duringmultiple repetitions (5-10) of weighted (0.5-5kg [1-10 lb]) shoulder flexion.

c. Observation of scapular motion during perfor-mance of resisted isometric external rotation

ATHLETIC THERAPY TODAY SEPTEMBER 2006 I 13

with the arm at the side in neutral rotation(scapular flip sign).

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

e. Performance of the manual scapular-assistancetest and scapular-retraction test to determine thecontribution of scapular dysfunction to shouldersymptoms.

f. Evaluation of specific soft-tissue mobility pat-terns such as posterior-capsule or rotator-cuffhypomobility and pectoraiis-minor tightness.

g. Screening for forward head posture, forwardshoulder posture, and thoracic kyphosis usinga side-view plumb line.

4. A thorough clinical evaluation of the scapula thatdemonstrates specific impairments (e.g., dyskine-sis and hypomobility) should be used to determinespecific treatment interventions (e.g., strengthen-ing and mobilization).

5. Further research into the diagnostic and prognosticvalue of clinical tests to evaluate scapular dysfunc-tion is needed. I

References1. Johnson MP. van den Heuvel V, Sauers EL. Reliability of a classifica-

tion protocol for the assessment of scapular motion in patients withshoulder pathology. Paper presented at: 1st International Congressof Shoulder and Elbow Therapists; 2004; Washington DC.

2. Johnson MP, Addesi S, Ebaugh DD. Development of a model to clas-sify scapular motion: a pilot study Paper presented at: Meeting of thePennsylvania Physical Therapy Association; 2001: Harrisburg. Pa.

3. Kibier WB. Uhl TL. Maddux jWQ, Brooks PV, Zeller B. McMullen j .Qualitative clinical evaluation of scapular dysfunction: a reliabilitysmdy. J Shoulder Elbow Surg. 2003; 11 (6):550-556.

4. T^te AR, McClure P, NeffN. Validation of a visual classification systemfor scapular moiion dysfunction [abstract].y Orthop Sports Phys Ther.2004;34|l) A42

5. Gard K, Ebaugh DD, Bilgin S, Sakaitis C. Interrater reliability of aproposed scapular classification system [abstract]. _/ Orthop SportsPhys Ther. 2005\35{\y.A7.

6. Gard K, FinocchiaroJ, Ebaugh DD, Interrater reliability of a proposedscapular classification system [abstract]. J Orthop Sports Phys Ther.2006;36(l):A10,

7. McClure PW. Tate AR. Egner MC, Greenberg EM, Yops RM, Neff NPDevelopment and interrater reliability testing of a system of classifi-cation for scapular dysfunction {absiraa]. J Orthop Sports Phys Ther.2OO3;33(2):A23.

8. Kelly MJ, Brenneman SK. An examination sign to identify the presenceof a spinal accessory nerve palsy [abstract] .J Orthop Sports Phys Ther.2000:30(1) A27,

9. Kendall F, McCreary E, Provance P, Rodgers M, Romani W. Muscles:Testing and Function With Posture and Pain. Baltimore, Md: LippincottWilliams SWilkins: 2005

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

11. Tsai NT McClure PW, Karduna AR. Effects of muscle fatigueon 3-dimensional scapular kinematics. Arch Phys Med Rehabil.2003:84(7):1000-]005.

12. Michener LA, Boardman ND, Pidcoe PE, Frith AM. Scapular muscletests in subjects with shoulder pain and functional loss: reliability andconstruct validity. Phys Ther. 2005;85(ll):li28-]138.

13 Kibler WB, Livingston B. Closed-chain rehabilitation for upper andlower extremities. J ^ m Acad Orthop Surg. 2001 ;9(6):412-421.

14. 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;l9(6):64l-661.

I 5. Kibier WB, McMullen J. Scapular dyskinesis and its relation to shoulderpain. J Am Acad Orthop Surg. 2003; 11 (2): 142-151.

16. Borich M, Bright J, Loreilo D, Cieminski C, Buisman T. Ludewig PM.Scapular motion alterations in cases of glenohumeral internal rotationdeficit [abstract].]Orthop Sports Phys Ther. 2006;36(l):A3l.

17. Borstad JD, Ludewig PM. The effect of long versus short pectoralisminor resting length on scapular kinematics in healthy individuals.yOrthop Sports Phys Ther. 2005;35(4):227-238.

18. Tyler TF, Roy T Nicholas SJ, Gleim GW Reliability and validity of a newmethod of measuring posterior shoulder tightness, y Orthop SportsPhys Ther. 1999;29(5):262-269, discussion 270-274.

19. Wang S, Trudell-Jackson E. Tossey L, Vo W, Theriault T Effectivenessof two physical therapy interventions for increasing length in the pec-toralis minor muscle [abstract] y Orthop Sports Phys Ther. 2006;36( I):All.

20. Lewis JS, Green A, Wright C. Subacromial impingement syndrome:the role of posture and muscle imbalance J Shoulder Elbow Surg.2005;14(4):385-392.

21. Michener LA, McClure PW, Karduna AR. Anatomical and biomechani-cal mechanisms of subacromial impingement syndrome. Clin Biomech(Bristol. Avon). 2003;i8(5):369-379.

22. Wang CH, McClure P, Pratt NE, Nobilini R. Stretching and strengthen-ing exercises: their effect on three-dimensional scapular kinematics.Arch Phys Med Rehabil. 1999;80(8):923-929

23. Finley MA, Lee RY. Effect of sitting posture on 3-dimensional scapularkinematics measured by skin-mounted electromagnetic tracking sen-sors. Arch Phys Med Rehabil. 2003;84(4):563-568.

24. Lukasiewicz AC, McClure P, Michener L, Pratt N, SennettB. Comparisonof 3-dimensional scapular position and orientation between subjectswith and without shoulder impingement.y Orfftop Sports Phys Ther.l999:29(10):574-583, discussion 584-586.

25. KuhnJE, PlancherKD, Hawkins RJ. Scapu]ar winging. J Am Acad OrthopSurg. l995;3(6):319-325.

26. Warner JJ, Micheli LJ, Arslanian LE. Kennedy J, Kennedy R. Scapu-lothoracic motion in normal shoulders and shoulders with glenohu-meral instability and impingement syndrome, a study using moiretopographic analysis. Ciin Orthop. 1992;285(199): 191 -199.

Eric Sauers is an associate professor and director of the athletic trainingprogram, as well as chair of the Department of Interdisciplinary HealthSciences, at Arizona School of Health Sciences, A.T. Still University,

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