Scapular Dyskinesis: What is it and how to fix it?

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In order to have good shoulder movement, we must also have good scapular, or shoulder blade, mobility. When the right scapular kinematics are missing, then you develop what’s known as scapular dyskinesis.

Scapular dyskinesis describes an abnormal scapular movement and incorrect scapular position. The reasons behind scapular dysfunction can vary, but when present, it will always affect shoulder function and mobility.

Sometimes this can lead to pain because the shoulder joint isn’t being properly supported.

The good news is you can treat scapular dyskinesis!

The Role of the Scapula

scapular dyskinesia


The scapula works in harmony with the shoulder joint and thoracic spine to allow normal, smooth and stable shoulder movement.

Without this, shoulder pain and shoulder injuries can occur.

The scapula plays multiple roles, including the following:

  • Rotation during arm elevation
  • A foundation for the rotator cuff muscles
  • A vital piece in mobility of the entire shoulder complex (e.g., glenohumeral joint, acromioclavicular joint, thoracic spine)

Scapulohumeral Rhythm

Shoulder movement, particularly overhead motions, such as abduction, requires harmony between the scapulothoracic (scapula and thoracic spine) region and the glenohumeral joint, or shoulder joint.

This harmonious movement is also known as scapulohumeral rhythm.

The basic concept of scapulohumeral rhythm is that the glenohumeral joint and the scapulothoracic joint move in a 2:1 ration with overhead motions.

For example, in order to raise the arm into 100 degrees of abduction (movement of the arm out to the side and continuing overhead), there must be 50 degrees of upward rotation at the scapula. These motions must occur concurrently.

If these scapular kinematics don’t occur, it will lead to shoulder dysfunction.

Anatomy of the Scapula

anatomy of the scapula

The scapula is part of the shoulder girdle, located in the upper back. There are 2 scapulae, one on each side of the spine.

The Joints

scapula joint

The front of the scapula is called the acromion. It connects the collar bone, or clavicle, to form the acromioclavicular joint.

The scapulothoracic connection is located between the scapula and thoracic ribs 2-7 (there are 12 total ribs).

The glenohumeral joint is formed by the head of the humerus (upper arm) and the scapula. This is a ball-and-socket joint. The head of the humerus is the ball and the scapular cavity creates the socket.

The Muscles

There are various muscle-tendon attachments that connect all the parts of the shoulder girdle.

The primary muscles in the upper extremity, upper back and chest that are responsible for shoulder
mobility and that attach in one way, shape or form to the scapula, include the following:

  • Rotator cuff muscles: supraspinatus, infraspinatus, subscapularis, teres minor
  • Rhomboid muscles: rhomboid major and rhomboid minor
  • Trapezius muscles: upper, middle and lower trapezius
  • Deltoid muscles: anterior, middle and posterior deltoid
  • Serratus anterior muscles
  • Latissimus dorsi muscles
  • Pectoralis minor muscle
  • Teres major muscle
  • Triceps brachii muscles

Causes of Scapular Dyskinesis

causes of scapular dyskinesis

Scapular dyskinesis can occur for a variety of reasons.

Muscle imbalance can lead to scapular dyskinesis. This may involve any of the scapular muscles.

With this issue, certain muscles surrounding the scapula will become overly tight, while others become excessively weak. This can cause altered scapular kinematics and scapular position.

Any shoulder injury affecting the shoulder muscles can lead to scapular dyskinesis. This can include one or more of the following shoulder disorders:

Nerve damage is a common cause for scapular dyskinesis, especially after a surgery. Nerves are responsible for innervating our muscles, so if there is nerve damage, there will be trouble with muscle activation.

Nerve Damage

Let’s dive in a bit more into possible nerve injuries that can lead to scapular dyskinesis, as this is one of the most common causes.

There are 3 important nerves when it comes to potential scapular dyskinesis:

  1. Long Thoracic Nerve: This innervates the serratus anterior muscles.

    The serratus anterior helps with scapular upward rotation, protracts and stabilizes the scapula. With damage to this nerve, the medial border (inward border) of the shoulder blade will wing.

  2. Spinal Accessory Nerve: This innervates the trapezius muscles.The upper trapezius muscle is responsible for elevation of the scapula, while the middle trapezius muscle is responsible for scapular retraction, and the lower trapezius muscle is responsible for scapular depression. Damage to this nerve will cause the lateral border (outward border) of the shoulder blade to wing.

  3. Dorsal Scapular Nerve: This innervates the rhomboid muscles. The primary role of the rhomboids is scapular retraction. They help to stabilize the scapula against the thoracic wall. Damage to this nerve will cause the lateral border (outward border) of the shoulder blade to wing.

Damage to the long thoracic nerve is the most common type of nerve injury to cause scapular dyskinesis.

Symptoms of Scapular Dyskinesis

symptoms of scapular dyskinesis

If you are experiencing scapular dyskinesis, you’ll most likely notice one or more of the following symptoms:

  • Pain and tenderness around the scapula
  • Decreased range of motion
  • Reduced muscle strength
  • Fatigue in the shoulder muscles
  • Shoulder instability
  • Shoulder pain
  • An abnormal scapular resting position: “winging” of the scapula
  • Forward posture

How to Diagnose Scapular Dyskinesis

If you suspect you may be experiencing scapular dyskinesis, contact your medical doctor for a more in-depth examination. You can consult with your primary care physician or an orthopedic specialist.

A. Physical Examination

diagnose scapular dyskinesis

During a physical exam, your doctor will visually examine your posture and scapular positioning.

They will have you perform overhead motions while observing and manually palpating the movement and behavior of the scapula.

They will also perform manual muscle testing to further determine which muscle groups are weaker and struggling to activate.

B. Special Tests

There are a couple orthopedic special tests that can be helpful for confirming a diagnosis of scapular dyskinesis. These are the scapular assistance test and the scapular retraction test.

1. Scapular Assistance Test

During the scapular assistance test, the examiner will provide manual assistance to the scapular motion of scapular upward rotation while you are performing arm elevation.

The scapular assistance test is considered a positive test if your symptoms improve and/or your range of motion increases with this assistance.

2. Scapular Retraction Test

During the scapular retraction test, the examiner will perform manual muscle testing by pushing down on your elevated arm as you resist. They will perform this with and without providing manual retraction of the scapula.

If your strength improves with manual retraction, then the test is considered positive for scapular dyskinesis and weakness.

C. Imaging

imaging of scapula

Imaging is not usually needed to make a diagnosis of scapular dyskinesis.

If your symptoms are related to a traumatic injury though or there is suspicion of another cause behind your symptoms, your doctor may order imaging tests.

These imaging tests may include an X-ray for assessment of the bony structures, or more in-depth testing via a CT scan or MRI for greater bone and soft tissue details.

Treatment of Scapular Dyskinesis

Treatment of scapular dyskinesis will primarily involve physical therapy.

If you’re experiencing a significant amount of shoulder pain in relation to your shoulder injury, your doctor may prescribe anti-inflammatory medications to relieve pain, in order to tolerate your physical therapy better.

physical therapy for treatment of scapular dyskinesis

Physical therapy will be focused on restoring scapular muscle balance and proper scapular kinematics, improving range of motion, and achieving scapular stabilization.

Rehabilitation of scapular dyskinesis will largely involve exercises to achieve the above goals.

Sometimes additional hands-on manual therapy (e.g., massage, myofascial release, trigger point release) and modalities (e.g., heat or cold therapy, electrical stimulation) may be used for additional pain management and recovery of shoulder function.

The following are examples of common exercises practiced in physical therapy for scapular dyskinesis.

1. Rows

A row will key in on middle trapezius and rhomboid muscle activation. This exercise can be performed either upright or bent over.

A. Upright Row Using a Resistance Band

scapular dyskinesis exercise: row
scapular dyskinesis exercise: row
  • Hold on to the ends of a resistance band (light, medium or heavy), which you can attach to a door knob.
  • Begin with the arms elevated in front of you to shoulder height and the palms facing each other.
  • Step back far enough that there is a little tension on the resistance bend.
  • Pull back on the band by bending the elbows and swinging the arms back next to you. Make sure to squeeze the shoulder blades together.
  • Hold for 2 seconds, then return to your starting position.
  • Repeat 10-15 repetitions for 2-3 sets.

B. Bent Over Row

bent over row
bent over row
  • You can use a resistance band (light, medium or heavy) anchored under your foot or a free weight (~3-5#) for this.
  • Sit back into a small mini squat, hinging forward at the hips (keep the back neutral).
  • Position the arms down and slightly forward in front of you. Palms face each other.
  • Squeeze the shoulder blades together as you bend the elbows and swing the arms back next to you.
  • Hold for 2 seconds, then return to your starting position.
  • Repeat 10-15 repetitions for 2-3 sets.

2. Serratus Punch

The serratus punch targets serratus anterior muscle activation.

serratus punch
serratus punch
  • You’ll be laying on your back for this exercise (floor, bed or couch is fine). Keep the knees bent and feet flat on the surface to support the back.
  • You can use free weights (~3-5#), or if no free weights are available can substitute for a similarly weighted object (e.g., soup cans).
  • Begin with the arms extended and pointing directly to the ceiling. Palms facing each other.
  • Keeping the arms straight, lift the shoulder blades off the floor, punching towards the ceiling.
  • Hold for 2 seconds, then lower back to your starting position.
  • Repeat 10-15 repetitions for 2-3 sets.

3. Shoulder Extension with a Resistance Band

Shoulder extension will target lower trapezius, proximal triceps, and the latissimus dorsi muscle activation.

shoulder extension with a resistance band
shoulder extension with a resistance band
  • Hold on to the ends of a resistance band (light, medium or heavy), which you can attach to a door knob.
  • Begin with the arms elevated in front of you to shoulder height and the palms facing down towards the floor.
  • Squeezing the shoulder blades down and back, pull back on the resistance band and swing the arms back until they are next to you.
  • Hold for 2 seconds, then lower back to your starting position.
  • Repeat 10-15 repetitions for 2-3 sets.

4. Shoulder External Rotation

Shoulder external rotation targets the rotator cuff and scapular muscles. Not only is this helpful for scapular dyskinesis, but also for a rotator cuff injury.

shoulder external rotation
shoulder external rotation
  • You can use a resistance band (light, medium or heavy) or free weights (~3-5#) for this.
  • Begin with the elbows bent 90 degrees, palms facing each other, and upper arms tucked by your side.
  • As you squeeze the shoulder blades together, move the forearms out and away from each other.
  • Hold for 2 seconds, then lower back to your starting position.
  • Repeat 10-15 repetitions for 2-3 sets.

5. Thread the Needle Stretch

This stretch is commonly seen in yoga practice. It targets posterior shoulder tightness.

thread the needle stretch
thread the needle stretch
  • Begin on the hands and knees (can practice on the floor or your bed).
  • As you sit back towards the heels, keep one arm extended forward (like child’s pose in yoga).
  • Reach the other arm towards its opposing side, so that the resting position is with the back of the arm on the ground between the outstretched arm and your legs.
  • Hold at least 30 seconds or up to 1 minute, then repeat on the opposite arm.

If you need a little more guidance with this stretch, check out this video for a full demonstration.

6. Shoulder Abduction Stretch

This is another stretch that targets posterior shoulder tightness.

shoulder abduction stretch
shoulder abduction stretch
  • Position the arm to be stretched across the chest.
  • Take the other arm and hook it under the arm to be stretched.
  • Slowly pull the arm to be stretched for a gentle overpressure.
  • Hold at least 30 seconds or up to 1 minute, then repeat on the opposite arm.

Progressing Your Exercise Routine

It’s recommended to begin with a lighter dosage of exercise, then gradually increase the challenge and intensity.

By doing so, you’ll reduce your chances of flaring pain and straining the targeted scapular stabilizing muscles.

Your physical therapist will help guide your exercise progression, but here are some basic tips for home.

  1. Increase the number of repetitions and sets.
  2. Increase the amount of weight or resistance you’re using.
  3. Change the position of the exercise.
  4. Be sure to practice strengthening at various angles to target multiple muscle groups.

An example of practicing various angles is progressive resistance exercises in a prone position, or laying on the stomach.

In this position, you can strengthen the shoulder joint and shoulder scapular muscles by moving the arms three different ways:

  1. Forward arm elevation with the thumbs up (targets the upper trapezius muscle strength)
  2. Horizontal abduction with the thumbs up (targets the middle trapezius and rhomboid muscle strength)
  3. Extension (targets the lower trapezius, latissimus dorsi, and proximal triceps muscle strength)

Take a look at this full video demonstration of how to perform the above exercise circuit.

Don’t be afraid to combine different exercises if they mesh well together.

For example, you can take the concept of a serratus punch and combine it with a wall push up.

Performing a push up on a wall is a great alternative to the floor if you find the floor more challenging. Challenge the triceps with the actual push up, but then once you push back up, round the shoulder blades to activate the serratus anterior.

It’s that simple!

If you’re having trouble picturing this exercise combination, here’s a visual to help.

Key Takeaways

key takeaways for scapular dyskinesis

If your shoulder function is suffering because of scapular dyskinesis, this absolutely can be treated.

Rehabilitation of scapular dyskinesis can take some time, but is very achievable.

It’s important to identify what the exact cause of the scapular dysfunction is in order to properly treat it.

Once the right scapular kinematics have been restored, along with a normal scapular muscle balance, you’ll notice the effects immediately.

What once was causing shoulder pain and limited arm movement will finally be eliminated!

FAQ:

Can my shoulder blade winging go away on its own?

It’s not likely scapular dyskinesis, or winging, will resolve solely by itself. While it largely depends on the cause, the shoulder blade will typically need to be rehabilitated.

Could a back or postural brace put my shoulder blade back into alignment?

While there are postural braces meant to encourage keeping the shoulders pulled back in an upright position, this is a passive tool. It’s important to actively re-train the scapular muscles to support the shoulder blade and shoulder joint on their own.

Will I need surgery for my scapular dyskinesis?

Surgery is usually not needed to correct scapular dyskinesis, unless the underlying cause involves a torn muscle or tendon, or bone fracture, that will not heal properly without surgery.

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