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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

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.
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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 season. 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
Address for correspondence: Dr. Hariharasudhan Ravichandran,
Department of Physiotherapy, Sree Balaji college of
Physiotherapy, Chennai, Tamil Nadu, India.
E‑Mail: hrkums63@gmail.com
This is an open access article distributed under the terms of the Creative Commons
Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak,
and build upon the work non-commercially, as long as the author is credited and the new
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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
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]
Archives of Medicine and Health Sciences / Jul-Dec 2016 / Vol 4 | Issue 2
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
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Ravichandran and Janakiraman: Case Study on Scapular Dyskinesis
was done for serratus anterior, and lower trapezius was done
at a frequency of ten repetitions per session, 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 5th 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,
246
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.
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Ravichandran and Janakiraman: Case Study on Scapular Dyskinesis
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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