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Scapular Dyskinesis

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Other Names

  • Scapular Dyskinesia
  • Scapulothoracic Dyskinesis
  • Sicks Scapula Syndrome
  • Scapular Malpositioning
  • Scapular Dysfunction
  • Scapular Motion Abnormality
  • Abnormal Scapular Kinematics
  • Scapular Instability
  • Scapular Maltracking
  • Altered Scapulothoracic Mechanics

Background

  • This page refers to abnormal movement, typically called dyskinesis or dyskinesia of the Scapula

History

  • Needs to be updated

Epidemiology

  • Present in as many as 67% to 100% of athletes with shoulder injuries[1]

Pathophysiology

illustration of abnormal scapular movement
Anatomy of the scapula[2]
(A) Type I scapular dyskinesis. (B) Type II scapular dyskinesis. (C) Type III scapular dyskinesis.[3]
Prime movers and stabilizers of the scapula: upper and lower trapezius with serratus anterior[4]
Six patients with shoulder girdle weakness and scapular dyskinesis. Upper row—left image (patient 10): age 65 years, adult form DM1, onset scapular dyskinesis at age 12 years, D4Z4 repeat of 9 on chromosome 4qA, SD type 3 on both sides, overactivation of rhomboideus minor muscles. Middle image (patient 25): age 35 years, adult form DM1, onset scapular dyskinesis at age 10 years, FSHD negative, SD type 3 on the right side. Right image (patient 6) age 54 years, adult form DM1, onset scapular dyskinesis at age 48 years, FSHD negative, SD type 3 on the left side. Bottom row—left image (patient 11): age 21 years, congenital form DM1, onset scapular dyskinesis at age 20 years, FSHD not tested SD type 3 on both sides, severity R > L, rhomboid minor over active. Middle image (patient 31): age 30 years, congenital form DM1, onset scapular dyskinesis at age 20 years, FSHD not tested, Sd type 2 on the right side. Right image (patient 29): age 28 years, infantile form DM1, onset scapular dyskinesis at age 26 years, FSHD negative, SD type 1 on the right side and type 3 on the left side[5]

General

  • Considered non-specific response to a painful shoulder condition rather than a specific response to certain glenohumeral pathology
  • Often associated with comorbidities that lead to the dysfunction rather than being a primary problem
  • Diagnosis is generally clinical and management primarily associated with exercise therapy

Role of Scapula[6]

  • Provides synchronous scapular rotation during humeral motion
  • Serves as a stable base for Rotator Cuff activation
  • Functions as a link in the kinetic chain

Scapular dyskinesis definition[7]

  • 1: Abnormal static scapular position and/or dynamic scapular motion characterized by medial border prominence
  • 2: Inferior angle prominence and/or early scapular elevation or shrugging on arm elevation; and/or
  • 3: Rapid downward rotation during arm lowering

Associated Conditions

Anatomy of the Scapula

Risk Factors

  • Overhead athletes[8]

Differential Diagnosis

Differential Diagnosis Shoulder Pain

Clinical Features

Examine for factors contributing to scapular dyskinesis[9]
Clinical exam progression[9]
Type II scapular dyskinesis[10]
Demonstration of the Isometric Scapular Pinch Test

History

  • Most patients report pain, up to 83%[11]
  • Often report inability to achieve desired function in important activities
  • Worse with overhead activities or throwing motions
  • Sensation of shoulder instability or weakness
  • They may have a history of some other shooulder pathology (rotator cuff, labral tear, impingement, etc)[12]
  • There may be a history of prior kinetic chain injuries affecting hip, trunk or core[13]

Physical Exam: Physical Exam Shoulder

  • Inspection
    • Scapular exam done primarily posteriorly with shirt removed (if possible) for complete visualization
    • Important to evaluate resting posture checking for for side-to-side asymmetry, especially inferior or medial border prominence
    • Observe scapular resting position for asymmetry, protraction, or winging
    • Assess overall posture and shoulder positioning
  • Dynamic Assessment[14]
    • Evaluate dynamic scapula position by slow ascent-descent of shoulder 5-10 times with shoulder flexion and abduction
    • Testing in forward flexion shows higher frequency of multiple-plane asymmetries in symptomatic patients[15]
  • Common dyskinetic patterns include[16]
    • Scapular protraction (most common finding)
    • Loss of inferior medial border control
    • Prominence of the medial or inferior scapular border
    • Early or excessive scapular elevation during arm raising

Special Tests

Evaluation

Scapular winging seen on a PA radiograph[17]

General

  • Primarily a clinical diagnosis
  • Imaging is useful to help exclude other etiology in uncertain cases
  • Useful to identify primary diagnosis

Radiographs

  • Standard Radiographs Shoulder
    • Typically normal
  • Can measure specific parameters
    • Coracoid upward shift distance (CUSD)
    • Length of the scapular spine line (LSS)
    • Scapular upward rotation angle (SURA)
  • Interpretation of parameters[18]
    • Differences in CUSD >1.1 mm are characteristic of type I dyskinesis
    • Differences in LSS >1.2 mm suggest type II dyskinesis

CT

  • Three-dimensional wing CT[19]
    • Allows precise quantification of scapular position and has very high inter-rater reliability (0.972-0.981)
    • Measures: upward rotation (UR), superior translation (ST), anterior tilting (AT), protraction (PRO), and internal rotation (IR)
    • Cutoff values have been established: UR 117°, ST 90°, AT 8°, PRO 99°, and IR 51°
    • Type III dyskinesis shows increased UR and ST angles, while type I demonstrates increased AT angle.

MRI

  • Can be useful to confirm the etiology of dyskinesis and guide treatment decisions[20]
  • MRI is particularly useful when combined with plain radiographs and CT to establish a precise diagnosis

Ultrasound

  • Can evaluate neuromuscular causes of scapular winging
  • Can quantify medial border deviation from the thoracic wall[21]
    • Dyskinetic scapulae showing significantly greater motion (24.6 mm) compared to non-dyskinetic scapulae (12-15 mm)

Classification

Kibler Classification

  • Type I or Inferior dysfunction[22]
    • Primary external visual feature is the prominence of the inferior angle
    • Most commonly found in patients with rotator cuff dysfunction.
  • Type 2 or Medial dysfunction
    • Primary external visual feature is the prominence of the entire medial scapular border
    • Medial pattern dysfunction most often occurs in patients with glenohumeral joint instability.
  • Type 3 or Superior dysfunction
    • Characterized by excessive and early elevation of the scapula during upper extremity elevation.
    • Most often seen in patients with rotator cuff dysfunction and deltoid-rotator cuff force couple imbalances

Management

Assessment of dynamic scapular dyskinesis using the scapular dyskinesis test.[23]
Potential early exercises dependent on response to symptom modification[24]

General Approach

  • Begins with a comprehensive evaluation to identify causative factors[6]
  • Followed by scapula-focused exercise programs that address muscle imbalances, mobility deficits, and motor control dysfunction.

Nonoperative

  • First line treatment
  • Primary treatment is directed at the underlying pathology
  • Activity modification
    • Including correcting of throwing mechanics
  • Medications including NSAIDS
  • Physical Therapy
    • Emphasis on core strengthening, scapular stabilizers, rotator cuff, serratus anterior
  • Corticosteroid Injection

Adjunctive Therapies

Operative

  • Indicated only if primary injury or pathology is considered surgical
  • Techniques
    • Arthroscopic pectoralis minor tendon release
    • Acromioplasty

Rehabilitation and Return to Play

Some early phase rehab exercises[27]
Scapular stabilization exercises[28]

Rehab

  • Emphasis[29]
  • Specific exercise strategies
    • Modified shrug exercises to facilitate upward rotator muscles[30]
  • Early-phase exercises[31]
    • Low row and inferior glide
    • Wall slides
  • Progressive exercises requiring larger movements
    • Lawnmower and robbery exercises
    • Prone horizontal abduction with external rotation
    • External rotation in side lying

Exercise Rehab Program PDFs

Return to Play

  • Return to play criteria should include[13]
    • Resolution or significant reduction in pain during sport-specific movements
    • Restoration of full shoulder range of motion
    • Normalized scapular position and motion patterns
    • Adequate strength of scapular stabilizers and rotator cuff
    • Successful completion of sport-specific functional testing without pain or dyskinesis

Prognosis and Complications

Prognosis

  • Generally has a favorable prognosis with conservative treatment
  • Most patients respond well to targeted rehabilitation within 6 weeks
    • Scapular dyskinesis resolvs in approximately 78% of cases following a structured 12-week exercise protocol[32]
  • Prognosis is more favorable when dyskinesis is addressed early, underlying causitive factors are identified
    • Scapular dyskinesis appears to be a nonspecific response to shoulder dysfunction rather than a specific pathology

Complications

  • Perpetuation of shoulder pathology[33]
  • Subacromial Impingement Syndrome
  • Chronic Pain and Dysfunction
  • Development of SICK Syndrome[32]
    • Patients may develop Scapular malposition, Inferior medial border prominence, Coracoid pain and malposition, and dysKinesis (SICK syndrome)

See Also

Internal

External

References

  1. ↑ Pluim BM. Scapular dyskinesis: practical applications. Br J Sports Med. 2013;47:875–876.
  2. ↑ Mancuso, Matteo. Evaluation and robotic simulation of the glenohumeral joint. Diss. EPFL, 2020.
  3. ↑ Preziosi Standoli, Jacopo, et al. "Scapular dyskinesis in young, asymptomatic elite swimmers." Orthopaedic journal of sports medicine 6.1 (2018): 2325967117750814.
  4. ↑ Roche, S. J., et al. "Scapular dyskinesis: the surgeon's perspective. Shoulder Elbow 2015; 7: 289-97."
  5. ↑ Voermans, N. C., et al. "Scapular dyskinesis in myotonic dystrophy type 1: clinical characteristics and genetic investigations." Journal of neurology 266.12 (2019): 2987-2996.
  6. ↑ 6.0 6.1 Kibler, W. Ben, and Aaron Sciascia. "Current concepts: scapular dyskinesis." British journal of sports medicine 44.5 (2010): 300-305.
  7. ↑ Second Scapula Summit. Unpublished consensus statement. Lexington, Kentucky, USA. 20 July 2006
  8. ↑ Matthew B. Burn, Patrick C. McCulloch, David M. Lintner, Shari R. Liberman, and Joshua D. Harris Prevalence of Scapular Dyskinesis in Overhead and Nonoverhead Athletes: A Systematic Review Orthopaedic Journal of Sports Medicine February 2016 vol. 4 no. 2
  9. ↑ 9.0 9.1 Sciascia, Aaron, and W. Ben Kibler. "Current views of scapular dyskinesis and its possible clinical relevance." International journal of sports physical therapy 17.2 (2022): 117.
  10. ↑ Merolla, Giovanni, et al. "Infraspinatus scapular retraction test: a reliable and practical method to assess infraspinatus strength in overhead athletes with scapular dyskinesis." Journal of Orthopaedics and Traumatology 11.2 (2010): 105-110.
  11. ↑ Smith-Forbes, Enrique V., et al. "Descriptive analysis of common functional limitations identified by patients with shoulder pain." Journal of sport rehabilitation 24.2 (2015): 179-188.
  12. ↑ Kibler, Benjamin W., Aaron Sciascia, and Trevor Wilkes. "Scapular dyskinesis and its relation to shoulder injury." JAAOS-journal of the American academy of orthopaedic surgeons 20.6 (2012): 364-372.
  13. ↑ 13.0 13.1 Herring, Stanley A., et al. "Initial assessment and management of select musculoskeletal injuries: a team physician consensus statement." Current Sports Medicine Reports 23.3 (2024): 86-104.
  14. ↑ Rossi, Denise Martineli, et al. "Intrarater and interrater reliability of three classifications for scapular dyskinesis in athletes." PloS one 12.7 (2017): e0181518.
  15. ↑ Uhl, Tim L., et al. "Evaluation of clinical assessment methods for scapular dyskinesis." Arthroscopy: the journal of arthroscopic & related surgery 25.11 (2009): 1240-1248.
  16. ↑ Giuseppe, Longo Umile, et al. "Scapular dyskinesis: from basic science to ultimate treatment." International journal of environmental research and public health 17.8 (2020): 2974.
  17. ↑ Image courtesy of radsource.us
  18. ↑ Chen, Kang, et al. "A preliminary exploration of plain-film radiography in scapular dyskinesis evaluation." Journal of Shoulder and Elbow Surgery 27.7 (2018): e210-e218.
  19. ↑ Park, Jin-Young, et al. "Revisit to scapular dyskinesis: three-dimensional wing computed tomography in prone position." Journal of shoulder and elbow surgery 23.6 (2014): 821-828.
  20. ↑ Morita, Wataru, Taiki Nozaki, and Atsushi Tasaki. "MRI for the diagnosis of scapular dyskinesis: a report of two cases." Skeletal radiology 46.2 (2017): 249-252.
  21. ↑ Totlis, Trifon, et al. "A computer tablet software can quantify the deviation of scapula medial border from the thoracic wall during clinical assessment of scapula dyskinesis." Knee Surgery, Sports Traumatology, Arthroscopy 29.1 (2021): 202-209.
  22. ↑ Kibler WB et al.Qualitative clinical evaluation of scapular dysfunction: a reliability study. J Shoulder Elbow Surg.2002;11:550-556
  23. ↑ Sayaca, Cetin, et al. "Scapular dyskinesis, shoulder joint position sense, and functional level after arthroscopic bankart repair." Orthopaedic Journal of Sports Medicine 9.8 (2021): 2325967120985207.
  24. ↑ Willmore, Elaine G., and Michael J. Smith. "Scapular dyskinesia: evolution towards a systems-based approach." Shoulder & Elbow 8.1 (2016): 61-70.
  25. ↑ Nowotny, Joerg, et al. "Evaluation of a new exercise program in the treatment of scapular dyskinesis." International journal of sports medicine 39.10
  26. ↑ Espejo-Antúnez, Luis, et al. "Effects of NMES-Guided Scapular Retraction Exercise Program in Amateur Female Handball Players with Scapular Dyskinesis Without Shoulder Pain: A Randomized Controlled Clinical Trial." Journal of Clinical Medicine 14.15 (2025): 5567.
  27. ↑ Moura, Katherinne F., et al. "Rehabilitation of subacromial pain syndrome emphasizing scapular dyskinesis in amateur athletes: a case series." International journal of sports physical therapy 11.4 (2016): 552.
  28. ↑ Yuksel, Ertugrul, and Sevgi Sevi Yesilyaprak. "Scapular stabilization exercise training improves treatment effectiveness on shoulder pain, scapular dyskinesis, muscle strength, and function in patients with subacromial pain syndrome: A randomized controlled trial." Journal of Bodywork and Movement Therapies 37 (2024): 101-108.
  29. ↑ Cools, Ann MJ, et al. "Rehabilitation of scapular dyskinesis: from the office worker to the elite overhead athlete." Br J Sports Med 48.8 (2014): 692-697.
  30. ↑ Pizzari, Tania, et al. "Modifying a shrug exercise can facilitate the upward rotator muscles of the scapula." Clinical Biomechanics 29.2 (2014): 201-205.
  31. ↑ Kibler, W. Ben, et al. "Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation." The American journal of sports medicine 36.9 (2008): 1789-1798.
  32. ↑ 32.0 32.1 Carbone, Stefano, Roberto Postacchini, and Stefano Gumina. "Scapular dyskinesis and SICK syndrome in patients with a chronic type III acromioclavicular dislocation. Results of rehabilitation." Knee Surgery, Sports Traumatology, Arthroscopy 23.5 (2015): 1473-1480.
  33. ↑ Kibler, Ben W., and John McMullen. "Scapular dyskinesis and its relation to shoulder pain." JAAOS-journal of the American academy of orthopaedic surgeons 11.2 (2003): 142-151.
Created by:
John Kiel on 7 July 2019 23:42:13
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21 January 2026 12:13:26
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