Clinical Evaluation of Scapular Dysfunction

ERIC L. SAUERS, PhD, ATC, CSCS • A.T. Still University

Clinical Evaluation
S capular dysfunction has been widely
implicated as a contributing factor to
Visualization
shoulder pathology. Thus, evaluations of Evaluation of the scapula requires full visu-
scapular motion and strength have been alization of the posterior thorax and both
described as key components of a com- scapulae. This can be achieved by having
prehensive shoulder examination. Some male athletes remove their shirts and by
methods for evaluating scapular function, appropriately draping female athletes in
however, might not yield sufficient infor- gowns tied at the neck and waist or having
mation from which to them wear swimsuit tops or sport bras that
Key Points make an informed clin- do not cover (thereby possibly stabilizing)
ical decision regarding the scapula (Figure 1). Comprehensive evalu-
Scapular evaluation should include repeti- appropriate interven- ation of the scapula includes observation of
tive loading of the scapula muscles. tions. Traditional evalu- scapular motion to detect scapular dyskinesis
ation of the scapula (aberrant scapular motion or winging).
Soft-tissue mobility assessment of the has often been limited
shoulder is an important aspect of scapular to nothing more then
evaluation. having patients raise
and lower their arms
Scapular special tests include the scapular-
assistance test and the scapular-retraction for several repetitions.
test. Unfortunately, observa-
tion during unweighted
Key Words: shoulder, dyskinesis, clas- arm elevation is often
sification insufficient to detect
scapular dysfunction
because it fails to load and challenge the
scapulothoracic musculature.1 Three-dimen-
sional measurement of scapular kinematics
has provided a great deal of information
regarding normal and abnormal scapular
function, but these methods are not readily
available or practical in the clinical setting.
Determining appropriate clinical tests to
evaluate scapular dysfunction can be a
challenge. Therefore, the objective of this
article is to present methods for evaluat-
ing scapular dysfunction that will help
clinicians develop an appropriate course Figure 1  Weighted bilateral shoulder-flexion testing to
of intervention. evaluate scapular motion.

© 2006 Human Kinetics • ATT 11(5), pp. 10-14

10  september 2006 Athletic Therapy Today

Classification Protocols Manual Muscle Testing
Several investigators1-7 have reported on the develop- In addition to scapular-motion assessment, a thorough
ment of scapular-assessment protocols that incorpo- assessment of muscle strength should be performed
rate specific tests designed to load and challenge the using graded manual muscle tests9 for the scapula-
periscapular musculature in order to detect and clas- stabilizing muscles including the serratus anterior,
sify movement dysfunction.Johnson et al.2 developed rhomboids, and middle, upper, and lower trapezius.
a protocol that was later refined and used to evaluate These muscles are the primary scapular stabilizers,
27 patients with active shoulder pathology (N = 32).1 and changes in their strength have been implicated in
Their data indicated that three simple clinical tests altered scapular kinematics and subacromial impinge-
should be performed to detect abnormal scapular ment.10,11 Michener et al.12 have demonstrated that a
motion: (a) observation of bilateral scapular motion single clinician can reliably assess these muscles using
during multiple repetitions (5–10) of unweighted a handheld dynamometer in patients with pain and
humeral elevation in the scapular plane to establish a functional loss.
baseline of scapular movement, (b) observation of bilat-
eral scapular motion during multiple repetitions (5–10) Scapular Special Tests
of weighted (0.5–5 kg [1–10 lb]) shoulder flexion, and The addition of scapular special tests including the
(c) observation of scapular motion during performance scapular-assistance test and scapular-retraction test
of resisted isometric external rotation with the arm at might prove useful in trying to determine whether
the side in neutral rotation (scapular flip sign8). It is scapular-motion abnormalities are contributing to a
important to note that an adequate amount of weight patient’s symptoms. The scapular-assistance test is
should be chosen to load the scapular musculature but performed by manually stabilizing the scapula on the
not exacerbate shoulder pain. thorax and assisting the inferomedial border in rotating
Several scapular-classification protocols have in a stable and coordinated fashion while the patient
evolved from the work of Johnson et al.,2 and each raises his or her arm (Figure 2).13,14 A positive test is
consists of similar test components that include when the patient reports a reduction of symptoms
unweighted and weighted flexion and abduction and
the scapular flip sign.1,2,4-7 Collectively these tests appear
to demonstrate acceptable intrarater1 and interrater1,6,7
reliability and percentage agreement.1,6,7 A positive test
for abnormal scapular motion with weighted flexion
has been shown to be a valid indicator of abnormal
scapular motion compared with three-dimensional
kinematic measures.4
Of all of the tests reported, weighted shoulder
flexion has consistently been identified as the single
clinical test most highly associated with abnormal
scapular motion (Figure 1).1,4,6 Johnson et al.1 reported
that weighted flexion and the scapular flip sign identi-
fied 100% of visible scapular-motion abnormalities.1
Gard et al.6 reported that weighted flexion identified the
most scapular-motion abnormalities (48/50), followed
by unweighted flexion (43/50), with lower values for
weighted (34/50) and unweighted abduction (29/50)
and resisted external rotation at neutral elevation
(scapular flip sign; 23/50). It is important to note that
the diagnostic value (accuracy, sensitivity, specificity,
and positive and negative predictive value) of these
tests in isolation, or as part of a classification protocol,
remains to be demonstrated. Figure 2 Scapular-assistance test.

Athletic Therapy Today september 2006  11

while you are manually stabilizing and assisting the
scapula through a full range of motion.
The scapular-retraction test is another special test
that can be performed to assess the contribution of
the scapulothoracic articulation to impairments such
as pain and muscle weakness.14 The test is performed
by manual and patient-assisted retraction and stabili-
zation of the scapula on the thorax (Figure 3). I prefer
to then have the patient move through a full range of
motion to assess any change in symptoms with manual
scapular stabilization. The scapular-retraction test has
been described as a test to assess the contribution of
scapular stability to muscle-force output.15 The athlete
begins the test by performing a traditional empty-can
test with no scapular retraction or stabilization. The
scapula is then retracted and manually stabilized,
and the test is repeated. If the patient demonstrates
greater strength during retesting with the scapula in
the retracted and stabilized position, the test is con-
sidered positive.
The scapular-assistance and scapular-retraction
tests are both designed to stabilize and position the
scapula on the thorax. Diminished pain or increased
muscle strength during these tests suggests that abnor-
mal scapular control is contributing to the patient’s
symptoms, and rehabilitative interventions should be
implemented to restore scapular stability and motor
control.14 The diagnostic value of these tests, however,
remains to be demonstrated.
Figure 3  Scapular-retraction test.
12  september 2006 Athletic Therapy Today
Soft-Tissue Mobility Assessment
Other useful adjuncts to clinical evaluation of the scap-
ula include various tests of soft-tissue mobility about
the shoulder. Soft-tissue restrictions such as decreased
posterior shoulder mobility or increased pectoralis-
minor tightness can lead to alterations in scapular
kinematics, including reduced posterior tilting, upward
rotation, or external rotation during arm elevation.8,16,17
Posterior-capsule or rotator-cuff tightness can be evalu-
ated by measuring passive isolated glenohumeral-joint
internal rotation or cross-body horizontal adduction.18
Pectoralis-minor tightness can be evaluated by mea-
suring, with the patient supine, from the treatment
table to the posterior acromion. Wang et al.19 recently
determined that, with the patient supine on a treat-
ment table, a linear distance between the posterior
acromion and the surface of the table of less than 2.5
cm is indicative of a short pectoralis minor.
Postural Assessment
Forward head posture, forward shoulder posture,
and thoracic kyphosis should be assessed as part of
any scapular evaluation.20-22 Collectively, this triad of
impairments has been widely implicated in shoulder
dysfunction.20,21 Patients with spinal posture changes
indicative of forward head and shoulder posture and
thoracic kyphosis, such as increased cervical extension
and thoracic flexion, demonstrate altered scapular
kinematics consistent with subacromial impinge-
ment.22,23 These postural malalignments are suspected
to inhibit scapular posterior tilt and external rotation
during arm elevation, thereby compromising the sub-
acromial space. A quick and efficient postural screen
for forward head posture, forward shoulder posture,
and thoracic kyphosis can be accomplished using the
side-view plumb-line screen (Figure 4).9
Intervention Implications
Patients with identifiable scapular impairments should
receive specific interventions to restore neuromuscu-
lar control, strength, and soft-tissue mobility and to
address postural malalignments. Treatment interven-
tions for scapular dysfunction should be based on
specific clinical-examination findings. For instance,
two patients with subacromial-impingement syndrome
might have differing scapular contributions to their
pain and dysfunction that require different treatment
strategies. One patient might demonstrate scapular
 have been given higher priority based on the physical
examination.
Alterations in scapular kinematics in the presence
of shoulder pathology have been well demonstrated.10,24
Visible scapular-motion abnormalities might be more
common, however, in cases of long-standing or more
severe shoulder pathology1 or in patients with nerve
injury.25 Furthermore, the evidence suggests that visible
scapular-motion abnormalities are more prevalent in
patients with the specific diagnoses of shoulder insta-
bility and shoulder-impingement syndrome.1,26
Proximal stability and neuromuscular control of
the scapula are critical to distal mobility and function
of the arm. A thorough and systematic evaluation of
the scapula to determine scapular-motion quantity and
quality, scapular-positioning contribution to pain and
strength, scapular-muscle strength, soft-tissue mobility,
and spinal posture should be central to every examina-
tion of the shoulder. This evaluation will help identify
specific impairments that might be contributing to
functional loss and disability and will serve to establish
clear priorities for treatment intervention. Nonetheless,
the prognostic value of scapular dysfunction in relation
to normal, pain-free shoulder function remains unclear.
More research is needed to evaluate the diagnostic and
prognostic value of scapular tests in specific patient
populations with well-defined shoulder pathology.

Figure 4 Postural assessment using the side-view plumb-line screen.

dyskinesis and scapular-muscle weakness that are
leading to altered scapular kinematics (decreased
posterior tilt, external rotation, and upward rotation).
This patient would probably benefit most from a thor-
ough scapular-stabilization and neuromuscular-control
rehabilitation program. The other patient might exhibit
coordinated and stable scapular motion but exhibit
significant pectoralis-minor and posterior-capsule or
-cuff tightness in addition to forward shoulder posture
and thoracic kyphosis that are contributing to altered
scapular kinematics (decreased posterior tilt, external
rotation, and upward rotation). This patient would most
likely benefit from specific manual therapies aimed
at restoring soft-tissue mobility and thoracic exten-
sion coupled with strengthening exercises to promote
thoracic extension and scapular retraction. Patients
with negative scapular-examination findings should
still receive core scapular-stabilization exercises, but
these might be adjunctive to other interventions that
Clinical-Evaluation Summary
1. The examiner must expose the posterior thorax
and scapulae by having male patients remove their
shirts or by draping female patients with a gown.
2. Visible observation of scapular-movement dysfunc-
tion usually requires that you repetitively challenge
the scapula under loaded conditions.
3. Clinical evaluation of the scapula should consist of
the following examination techniques:
a. Observation of bilateral scapular motion during
multiple repetitions (5–10) of unweighted shoul-
der flexion to determine a baseline.
b. Observation of bilateral scapular motion during
multiple repetitions (5–10) of weighted (0.5–5
kg [1–10 lb]) shoulder flexion.
c. Observation of scapular motion during perfor-
mance of resisted isometric external rotation

Athletic Therapy Today september 2006  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, and
middle, upper, and lower trapezius).
e. Performance of the manual scapular-assistance
test and scapular-retraction test to determine the
contribution of scapular dysfunction to shoulder
symptoms.
f. Evaluation of specific soft-tissue mobility pat-
terns such as posterior-capsule or rotator-cuff
hypomobility and pectoralis-minor tightness.
g. Screening for forward head posture, forward
shoulder posture, and thoracic kyphosis using
a side-view plumb line.
4. A thorough clinical evaluation of the scapula that
demonstrates specific impairments (e.g., dyskine-
sis and hypomobility) should be used to determine
specific treatment interventions (e.g., strengthen-
ing and mobilization).
5. Further research into the diagnostic and prognostic
value of clinical tests to evaluate scapular dysfunc-
tion is needed. 
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Eric Sauers is an associate professor and director of the athletic training
program, as well as chair of the Department of Interdisciplinary Health
Sciences, at Arizona School of Health Sciences, A.T. Still University.