Scapular Dyskinesis and SICK Scapula Syndrome in Patients

With Chronic Type III Acromioclavicular Dislocation

Stefano Gumina, M.D., Ph.D., Stefano Carbone, M.D., and Franco Postacchini, M.D., Ph.D.

Purpose: This study was aimed at evaluating whether scapular dyskinesis and, eventually, SICK
(Scapular malposition, Inferior medial border prominence, Coracoid pain and malposition, and
dysKinesis of scapular movement) scapula syndrome develop in patients with chronic type III
acromioclavicular (AC) dislocation. Methods: Scapulothoracic motion was studied in 34 patients
with chronic AC dislocation by use of the protocol described by Kibler et al. and Burkhart et al. An
anteroposterior radiograph of the scapulae with the arms abducted was also obtained. The SICK
Scapula Rating Scale was applied to patients with SICK scapula syndrome. Shoulder function was
assessed with the Constant score and Simple Shoulder Test (SST). Results: Of the 34 patients, 24
(70.6%) had scapular dyskinesis with the arms at rest, and 14 of these (58.3%) had SICK scapula
syndrome. The mean SICK Scapula Rating Scale score was 6.9 points (out of a possible 20 points).
Clinical and radiographic evaluations with the arms abducted at 90° confirmed scapular dyskinesis
in 61.7% and 64.7% of patients, respectively (P ⬎ .05). The Constant score was 83 points for the
pathologic side and 91 points for the contralateral side. The Constant score value was 75 and 88,
respectively, in patients with dyskinesis and those without dyskinesis (P ⬍ .05); the mean value for
the SST was 8 of 12 and 10 of 12, respectively. Conclusions: Chronic type III AC dislocation causes
scapular dyskinesis in 70.6% of patients. Of the latter, 58.3% have SICK scapula syndrome develop.
Dyskinesis might be due to loss of the stable fulcrum of the shoulder girdle represented by the AC
joint and due to the superior shoulder pain caused by the dislocation. The values for the Constant
score and SST were lower in patients with dyskinesis. Level of Evidence: Level IV, prognostic case
series. Key Words: Acromioclavicular joint dislocations—Type III acromioclavicular separation—
Scapular dyskinesis—SICK scapula syndrome.

A cromioclavicular (AC) joint injuries are com-

mon, especially in athletes. They represent 12%
of dislocations at the shoulder girdle and 8% of all
joint dislocations in the human body.1 The AC joint
stabilizes the scapula in relation to the clavicle by
means of a complex of ligaments and muscles. Al-
though the clavicle rotates upward 40° to 50° during
From the Department of Orthopaedic Surgery, University “La
Sapienza,” Rome, Italy.
The authors report no conflict of interest.
Received April 24, 2008; accepted August 27, 2008.
Address correspondence and reprint requests to Stefano Car-
bone, M.D., Department of Orthopaedic Surgery, University “La
Sapienza,” Piazzale Aldo Moro, 5, 00100, Rome, Italy. E-mail:
stefcarbone@yahoo.it
© 2009 by the Arthroscopy Association of North America
0749-8063/09/2501-8221$36.00/0
doi:10.1016/j.arthro.2008.08.019
full overhead elevation, only 5° to 8° of motion occur
in the AC joint.2 This difference is the result of “syn-
chronous scapuloclavicular” motion: as the clavicle
rotates upward, the scapula rotates downward, and AC
joint motion thereby decreases. This synchrony is
coordinated by the coracoclavicular ligaments.
Joint dislocation usually results from a direct blow
to the acromion with the arm adducted. The classifi-
cation of AC injuries is based on the type of anatomic
lesion, as well as the direction and amount of clavic-
ular displacement. The Rockwood classification,
which is the most commonly used system, includes 6
types of injury of increasing severity.3 This classifi-
cation defines the extent of injury and helps in the
management of AC joint injuries. Generally, types I
and II are treated conservatively with immobilization,
ice, and nonsteroidal drugs.4 On the other hand, types
IV, V, and VI almost always require surgical treat-

40 Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 25, No 1 (January), 2009: pp 40-45
 SICK SCAPULA SYNDROME
ment.4 The management of type III dislocation, char-
acterized by complete AC and coracoclavicular liga-
ment tears, as well as coracoclavicular interspace
greater than 25% to 100% of that in the normal shoul-
der, is controversial, although several prospective,
randomized, controlled trials have shown that the re-
sults of conservative treatment are better than those of
surgery.4-7 On the contrary, a recent study states that
surgical reconstruction guarantees better outcomes.8
Bagg and Forrest9 observed that AC joint injuries
associated with clavicle instability or osteoarthritic
changes of the joint interfere with clavicular function
and can affect scapular kinematics by not allowing the
normal progression of the instant center of scapular
rotation from the medial scapular border to the AC
joint.
Scapular dyskinesis is an alteration of the normal
position or motion of the scapula during coupled
scapulohumeral movements. It occurs after a large
number of injuries involving the shoulder joint and is
often a cause of shoulder pain.10 Warner et al11 found
alterations of the scapular position and motion in 68%
to 100% of patients with a history of shoulder injuries.
Three-dimensional biomechanical analysis of scapular
motions shows that the scapula moves around 3 axes
of motion simultaneously.12,13 Abnormal motion pat-
terns in scapular dyskinesis are best detected by first
determining the position of the scapula with the pa-
tient’s arms at rest and then observing the scapular
motion as the arms are elevated and lowered in the
scapular plane. These dyskinetic patterns fall into 3
categories, characterized by the prominence of the
inferomedial border of the scapula (type I), the entire
medial border (type II), or the superomedial border
(type III).14 Recently, Burkhart et al.15 have related the
disabled throwing shoulder to a particular overuse
muscle fatigue syndrome: “the SICK scapula.” The
acronym SICK stands for Scapular malposition, Infe-
rior medial border prominence, Coracoid pain and
malposition, and dysKinesis of scapular movement.
The main feature of this syndrome is the malposition
of the scapula in the dominant throwing shoulder,
which appears to be lower than the contralateral shoul-
der. Symptomatic patients may complain of anterior
shoulder pain in the region of the coracoid, postero-
superior scapular pain with or without radiation to the
paraspinous neck region or proximal lateral arm, su-
perior (AC joint) shoulder pain, or radicular symp-
toms.15 The authors have examined their overhead
throwing athletes with 3 superficial landmark mea-
surements of the scapula and have devised a grading
system for the severity of scapular malposition.
41
In this study we have analyzed patients with chronic
unreduced type III AC dislocation to determine
whether scapular dyskinesis and, eventually, SICK
scapula syndrome had developed. The kinematics of
the involved scapulothoracic joint was studied to un-
derstand why some patients with an AC joint disloca-
tion complain of pain in the AC joint, periscapular
muscles, and scapulovertebral region. We hypothe-
sized that this pain and the altered AC joint anatomy
may interfere with the scapulothoracic rhythm. To our
knowledge, this is the first study on the effects of a
longstanding type III AC dislocation and on the bio-
mechanics of the scapulothoracic joint.
METHODS
Between 2004 and 2007, 62 patients with radio-
graphic evidence of type III AC dislocation were
treated at our emergency department. Of these, 53
were treated conservatively whereas 9 underwent ar-
throscopic or open reduction of the dislocation.
Twelve patients were excluded from the study for one
of the following reasons: previous shoulder injury,
associated neurologic deficit on the side of the lesion
occurring at the time of dislocation, and age over 70
years at the time of follow-up. Patients with AC
osteoarthritis were also excluded because, although it
occurs rarely, they already had a painful shoulder
before the injury. Seven additional patients could not
be traced. All of the remaining 34 patients included in
the study group had been treated with a figure-of-8
splint for a mean of 4 weeks and early motion of the
upper limb. Thereafter, all patients followed a reha-
bilitation program for a mean period of 3 weeks. None
had sustained other significant shoulder injuries within
the follow-up period.
There were 32 male and 2 female patients, aged 24
to 69 years (mean, 47 years) at the time of follow-up.
The mean time interval between injury and follow-up
was 28 months (range, 12 to 36 months).
Scapulothoracic motion was separately evaluated
by all of the authors. According to the protocol of
Kibler et al.10,14 and Burkhart et al.,15 scapular posi-
tion was first analyzed with the arms at rest (position
1). In this position we evaluated (1) the difference in
height (in centimeters) of the superomedial scapular
angle between the injured and contralateral scapulae,
(2) the difference in the distance (in centimeters) of
the superomedial scapular angle from the body mid-
line between the injured and contralateral sides, and
(3) the difference in angular degrees, measured with a
goniometer, of the medial scapular border from the
42 S. GUMINA ET AL.

Once scapulothoracic dyskinesis was diagnosed, we

trained patients to follow the protocol described by
Kibler and McMullen10 for rehabilitation of scapular
dyskinesis, which emphasizes achieving full and ap-
propriate scapular motion and coordinating that mo-
tion with complementary trunk and hip movements.
The rehabilitation program reported by Burkhart et
al.15 was adopted for patients with SICK scapula syn-
drome.
Data are presented as means and were analyzed
with the nonparametric Wilcoxon test. P ⬍ .05 was
selected to indicate a statistically significant differ-
ence.

RESULTS

FIGURE 1. First measurement: Difference in vertical height of

In position 1 the difference in vertical height of the
superomedial scapular angle of injured scapula (A) compared with superomedial scapular angle of the scapula between
contralateral superomedial angle (B) (measured as number of cen- the injured and contralateral sides was 2.1 cm on
timeters from a to b) in position 1. Second measurement: Distance
of superomedial scapular angle (A, B) from midline in injured and
average (range, ⫺1 to 4.5 cm; P ⫽ .014). The mean
contralateral scapulae (centimeters from A to a minus centimeters difference in the distance of the superomedial scapular
from B to b). Third measurement: Difference in angular degrees of angle from the midline between the side with AC
medial scapular margin from plumb midline between injured scap-
ula (angle ␣) and contralateral scapula (angle ␤) measured with
dislocation and the contralateral side was 0.5 cm
goniometer. (range, ⫺2 to 2 cm; P ⫽ .208). The difference in
angular degrees of the medial scapular margin from
the plumb midline between the injured and contralat-
plumb line between the injured and contralateral scap- eral scapulae was 8° (range, ⫺10° to 10°; P ⫽ .041).
ulae (Fig 1). Considering 1.5 cm or 5° asymmetry as Of 34 patients, 24 (70.6%) had scapular dyskinesis,
the threshold for abnormality in each measure- with a Kibler type I pattern (prominence of inferome-
ment,15,16 we obtained the percentage of patients with dial border) in 17 (70.8%) (Fig 3), type II pattern
scapular dyskinesis. If abnormalities were noted, we (prominence of entire medial border) in 3 (12.5%)
ascribed them to 1 of the 3 patterns of scapular dys- (Fig 4), and type III pattern (prominence of supero-
kinesis described by Kibler et al.14 A history of cor- medial border) in 4 (16.6%) (Fig 5).14 SICK scapula
acoid pain was recorded, and coracoid position was syndrome was observed in 14 (58.3%) of the patients
assessed. For evaluating the severity of SICK scapula with scapular dyskinesis (Fig 6); the percentage was
syndrome, we applied the SICK Scapula Rating Scale 41.2% if all 34 patients were considered. The mean
to patients who had scapular dyskinesis, inferior me-
dial border prominence, and coracoid pain and mal-
position.15 This scale is based on measurements com-
paring the 2 scapula and investigating the subjective
and objective pain of the injured shoulder.
Subsequently, scapular position was assessed with
the arms abducted at 90° and internally rotated, the
elbows in full extension, and the hands holding a
weight of 2 kg (position 2) by use of the same param-
eters described previously. To verify the reliability of
clinical measurements, an anteroposterior radiograph
of both scapulae was obtained in position 2, and the
same measurements carried out on the patient’s body
were made (Fig 2). Finally, we evaluated shoulder
FIGURE 2. Anteroposterior radiograph of 2 scapulae with arms
function with the Constant score17 and Simple Shoul- abducted at 90°, used to evaluate same parameters assessed on
der Test (SST).18 clinical examination.
 SICK SCAPULA SYNDROME
FIGURE 3. Patient with chronic type III AC dislocation on left
side and type I pattern of dyskinesis (prominence of inferomedial
border of scapula).
score on the SICK Scapula Rating Scale in the 14
patients with SICK scapula syndrome was 6.9 points
(out of a possible 20 points) (range, 4 to 15 points)
(with ⬍5 points in 2 cases, 5 to 10 points in 9 cases,
and ⬎10 points in 3 cases).
In position 2 the difference in height of the supero-
medial scapular angle between the affected and con-
tralateral sides was 1.5 cm on average (range, ⫺1 to
3 cm; P ⫽ .032); the mean distance between the
FIGURE 4. Patient with chronic type III left AC dislocation on left
side and type II pattern of dyskinesis (prominence of entire medial
border). (Hypertrophy of the trapezius muscle does not allow AC
dislocation to be appreciated.)
43
FIGURE 5. Patient with chronic type III AC joint dislocation on
right side and type III pattern of dyskinesis (prominence of supero-
medial border).
superomedial scapular angle and the midline was 1 cm
(range, 0 to 2.6 cm; P ⫽ .142) greater on the injured
side than on the contralateral side; and the angle
formed by the medial scapular margin and the plumb
midline was 8° (range, ⫺8° to 18°; P ⫽ .047) greater
on the injured side. On the basis of these measure-
ments, 21 patients (61.7%) were found to have scap-
ular dyskinesis. At radiographic evaluation, the mean
difference in height of the superomedial scapular an-
gle between the injured scapula and the contralateral
scapula was 1.7 cm (range, ⫺2 to 3 cm; P ⫽ .029); the
mean difference in the superior scapular angle from
the midline between the injured and opposite sides
was 0.8 cm (range, ⫺2 to 3.3 cm; P ⫽ .208); and the
difference in the value of the angle formed by the
medial scapular margin and the plumb midline was 5°
(range, ⫺8° to 11°; P ⫽ .049) between the injured and
contralateral scapulae. On the basis of the radio-
FIGURE 6. Patient with chronic type III AC dislocation on right
side and SICK scapula syndrome.
44 S. GUMINA ET AL.
graphic results, 22 patients (64.7%) had scapular dys-
kinesis. However, the comparison of clinical to radio-
graphic measurements with the arms abducted at 90°
did not show a statistically significant difference (P ⫽
.47). No significant differences emerged when com-
paring the measurements performed by the 3 authors
(P ⫽ .052 to .124).
The mean Constant score was 83 points (range, 54
to 94 points) for the injured side and 92 points (range,
88 to 100 points) for the healthy side (P ⫽ .0087 for
comparison of the 2 groups). Patients with dyskinesis
examined in position 1 (n ⫽ 24) had a score of 75
points on average (range, 54 to 80 patients) on the
injured side, whereas patients with normal scapulo-
thoracic motion (n ⫽ 10) had a mean score of 88
points (range, 75 to 94 points). Comparison of the
Constant score in the last 2 groups of patients showed
a statistically significant difference (P ⫽ .01).
The mean SST score in the entire study group was
9 (out of a possible 12) (range, 6 to 12), with SST
scores of 8 and 10 in patients with dyskinesis and
those without dyskinesis, respectively.
DISCUSSION
In previous studies patients with shoulder pain
caused by different pathologic conditions were found
to have scapular dyskinesis.10 However, we could not
find any studies on the changes in scapulothoracic
motion as a result of type III AC joint dislocation.
According to Kibler et al.,14 scapulothoracic posi-
tion and motion should be studied using clinical mea-
surements carried out first with the arms at rest and
then with the arms abducted at 90° and internally
rotated and elbows in full extension. We adopted this
method, and in addition, we performed measurements
on anteroposterior radiographs of the shoulders with
the arms in abduction, because we thought that they
might be more accurate than clinical measurements.
However, no statistically significant difference was
found between the values obtained with the arms at
rest and those with the arms abducted or those calcu-
lated on the radiographs. These findings suggest that
scapular dyskinesis can be detected based solely on
the data obtained with the arms at rest (position 1).
They also indicate that measurements on radiographs
do not provide further information on scapular posi-
tion.
In this study 70.6% of patients with chronic AC
dislocation had scapular dyskinesis, and more than
two thirds of them had a prominence of the inferome-
dial border of the scapula. This abnormality of scap-
ular position was classified by Kibler et al.14 as a type
I pattern and was attributed to inflexibility of the
pectoralis major and minor, as well as to the weakness
of the lower trapezius and serratus anterior.14,15 This
biomechanical hypothesis may also explain the devel-
opment of scapular dyskinesis in patients with a
chronic AC joint dislocation. However, scapular dys-
kinesis might also be the result of chronic superior
shoulder pain or the loss of function of the AC joint as
a stable fulcrum of the shoulder girdle. In fact, in the
presence of dislocation, the AC joint could not allow
the normal progression of the instant center of scap-
ular rotation from the medial scapular border to the
AC joint.9
Prominence of the entire medial border and prom-
inence of the superior angle of the scapula were clas-
sified as a type II pattern and type III pattern, respec-
tively, and were attributed to weakness of the upper
and lower trapezius and rhomboid and to impingement
syndrome and rotator cuff diseases.14,15 The 30% of
our patients with scapular dyskinesis were equally
distributed among these 2 patterns. Superior shoulder
pain and loss of the stable fulcrum may again be the
cause of scapular dyskinesis development.
Of the patients with scapular dyskinesis in this
study, 3 of 5 had SICK scapula syndrome. In these
patients the mean score on the SICK Scapula Rating
Scale was 6.9 points (out of a possible 20 points).
Unfortunately, we were not able to find other articles
permitting comparison with our results. However, in
our experience, if this score was lower than 5 points
(as in 2 cases in our study), overhead activities were
not limited, whereas a score from 5 to 10 points meant
that such activities were painful but possible. The
score in 3 patients was higher than 10 points. They
could not substantially use the involved arm when
abducted or elevated over 90° and had shoulder pain-
ful at rest. In many studies conservative management
and surgical treatment of type III AC dislocations
were found to yield a similar proportion of satisfactory
results.4-7,19 However, in no article that analyzed con-
servatively treated patients was scapular dyskinesis
considered as a possible cause of shoulder dysfunc-
tion. In our study the mean Constant scores were 83
points and 92 points for the affected side and healthy
side, respectively. Furthermore, the mean Constant
score was 75 points in patients with scapular dyski-
nesis and 88 points in those without dyskinesis. The
fact that patients with dyskinesis have poorer results,
at least subjectively, than those without scapular mal-
position is confirmed by the different mean scores in
the 2 groups on the SST. Unfortunately, with the
 SICK SCAPULA SYNDROME
available data, no statistical analysis was performed
for this subjective evaluation scale.
Which is the best treatment in patients with a
chronic unreduced type III AC dislocation is still a
matter of discussion. Most of the abnormalities in
scapular motion or position can be managed by reha-
bilitation programs to re-establish muscle strength and
activation patterns.19-21 Kibler et al.10 obtained good
results with such programs in a high percentage of
patients with scapular dyskinesis not related to chronic
AC dislocation. Unfortunately, we do not know whether,
in these patients, physical therapy or surgical treat-
ment for chronic dislocation may cause the resolution
of dyskinesis.
One limitation of our study is that we do not know
what amount of scapulothoracic motion was present
before injury. Therefore it remains unclear whether
the injury is truly responsible for the dysfunction,
especially given the small number of patients studied.
In addition, it may be possible that patients who have
impaired scapulothoracic motion before injury are be-
coming worse after injury. We also did not compare
our cohort with a control group. However, in our
experience scapular dyskinesis affects only a small
percentage of normal subjects.
CONCLUSIONS
Chronic type III AC dislocation causes scapular
dyskinesis in 70.6% of patients, of whom 58.3% have
SICK scapula syndrome develop. Dyskinesis might be
due to loss of function of the AC joint as a stable
fulcrum of the shoulder girdle or due to the superior
shoulder pain caused by the dislocation. In our study
scapular dyskinesis was found to be correlated with
impaired shoulder function. In fact, the values for the
Constant score and SST were lower in patients with
dyskinesis compared with those without scapular mal-
position.
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