PEARLS OF PRACTICE
Managing Scapular Dyskinesis
Aaron Sciascia, PhD, ATC, PES
T
reatment of the scapula
and shoulder has tradition-
ally incorporated exercises
that have been shown to elicit large
amounts of muscle activity per elec-
tromyography. Although the semi-
nal studies identified maneuvers
that can actuate various muscles to
high degrees of electrical activity, the
foundational work was performed
on asymptomatic individuals. Fur-
thermore, the identified maneuvers
were often performed in an isolated
manner with the body in a vertical or
horizontal stationary position. Con-
sidering the scapula is a link within
the kinetic chain, these isolated ma-
neuvers may not reestablish scapular
mobility and control in the necessary
motor patterns that require integrat-
ed use of the majority of the kinetic
chain segments. Failure to incorpo-
rate the kinetic chain throughout the
rehabilitation process, from the ear-
lier phases of treatment through the
later phases, could lead to less than
optimal rehabilitation outcomes.
In some instances, the scapula and
shoulder can be overtly dysfunc-
tional. In these instances, minimiz-
ing the degrees of freedom via the
elimination of gravity-dependent
positions may be necessary. How-
From the Department of Exercise and Sport Science, Eastern Kentucky University, Richmond, Kentucky.
Submitted: May 1, 2019; Accepted: October 18, 2019
The author has no financial or proprietary interest in the materials presented herein.
Correspondence: Aaron Sciascia, PhD, ATC, PES, Department of Exercise and Sport Science, Eastern Kentucky
University, 228 Moberly Building, 521 Lancaster Avenue, Richmond, KY 40475. E-mail: aaron.sciascia@eku.edu
doi:10.3928/19425864-20191113-01
102
ever, the majority of clinical cases in-
volving scapular dysfunction should
allow for the incorporation of sitting
or standing positions in the early
phases of rehabilitation. As such, an
approach to manage altered scapular
motion in an integrated manner has
been described.
REHABILITATION
A kinetic chain rehabilitation
framework for shoulder dysfunction
describes a rehabilitation approach
that focuses on three critical charac-
teristics.1 First, patients are upright
during exercise performance rather
than positioned supine or prone
when possible to simulate func-
tional demands. Second, the lever
arm on the shoulder and trunk is
shortened to reduce the load on the
injured arm. Finally, arm motions
should be initiated using the legs
and trunk to facilitate activation of
the scapula and shoulder muscles,
which is a typical motor pattern of
motion. This framework was later
expanded to include a set of pro-
gressive goals2: (1) establish proper
postural alignment and motion; (2)
facilitate scapular motion via exag-
geration of lower extremity/trunk
movement; (3) exaggerate scapular
retraction in controlling excessive
protraction; (4) use the closed chain
exercise early; and (5) work in mul-
tiple planes.
Posture
In this first stage of the kinetic
chain approach, inflexibilities and
restrictions should also be ad-
dressed. These deficiencies can im-
pede progressions if left unattended
and delay the treatment process. Al-
tered posture is known to decrease
strength and motion at the gleno-
humeral joint and decrease motion
of the scapula.3 Proper posture and
motion can be achieved with a logi-
cal and progressive treatment plan
to restore skeletal segmental stabil-
ity and mobility through soft tissue
mobility and joint mobilization.
Employing interventions such as
stretching of the short head of the
biceps brachii and pectoralis minor
with a door frame stretch (Figure
1A), the infraspinatus/teres minor
with a cross-body stretch (Figure
1B), and the latissimus dorsi with a
prayer stretch (Figure 1C) are effec-
tive. Anterior directed joint mobi-
lizations for the thoracic spine/ribs
is recommended if immobility has
been identified in this area.
Caution should be taken if at-
tempting to manually mobilize the
scapula. Clinicians often place their
hands “under” the medial aspect of
the scapula in an attempt to stretch
the medially attached muscles or
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A B
Figure 1. (A) Doorframe stretch. (B) Cross-body stretch with stabilization of scapula. (C)
Prayer stretch.
loosen the fascial tissue. If performed
with too much force and/or com-
pression, this technique can have
deleterious consequences such as cre-
ating irritation between the muscles
and thorax or detaching the medial
muscles from the scapula. Instead,
clinicians should attempt to “glide”
the scapula in the superior, inferior,
medial, and lateral directions by plac-
ing one hand below the inferior angle
and above the supraspinous fossa.
Scapular Motion Facilitation
Arm function in front of the
body or overhead requires that the
scapula obtains a position of posterior
Athletic Training & Sports Health Care | Vol. 12
C noted above (Figure 2B). The patient
tilt and external rotation, which al-
lows optimal shoulder muscle activa-
tion that is synergistic with trunk and
hip musculature. This kinetic chain
pattern of activation then facilitates
maximal activation of the muscles at-
tached to the scapula. This integrated
sequencing allows the retracted scapu-
la to serve as a stable base for the origin
of all rotator cuff muscles, allowing
optimal concavity-compression to oc-
cur. Therefore, implementing scapular
stabilization exercises that incorporate
lower extremity stability and muscle
activation would be appropriate. For
example, shoulder exercises are often
performed with the body stationary.
No. 3 2020
PEARLS OF PRACTICE
This would be counterintuitive to the
kinetic chain concept because the arm
is being forced to perform as an iso-
lated structure rather than as part of
an integrated unit. Using a traditional
“row” for context, a patient would
be asked to sit or stand in a station-
ary position and then move the arms
from a forward flexed position with
the elbows extended to an extended
position with the elbows flexed (Fig-
ure 2A). The kinetic chain alternative
to this maneuver would be to simply
begin with the knees slightly flexed,
the trunk flexed at the waist, and the
arms in a forward flexed position as
would then actively extend the knees
and trunk while simultaneously mov-
ing the arms to the extended position
(Figure 2C). This added knee and
trunk motion “facilitates” scapular
motion by allowing the scapula to
more fully medially translate, which
in turn more closely mimics kinetic
chain function.
Patient position should also be
considered during rehabilitation ex-
ercise performance. It is common to
perform various shoulder exercises
in supine and prone positions. Al-
though patients can perform exercis-
es in these positions, it is questioned
whether they should instead perform
exercises while standing. This ques-
tion has merit because the standing
position allows a patient to use the
entire kinetic chain and be retrained
in motor control. The standing posi-
tion appears to decrease the chance
that one or more segments within
the kinetic chain could be overlooked
because they would be used in a man-
ner similar to activities of daily living
and sport. By this mechanism, the
standing position allows rehabilita-
tion to be more functional. Further-
more, greater amounts of joint posi-
tion sense errors at the shoulder have
103
 PEARLS OF PRACTICE
A B
been shown to occur when patients
are placed in supine positions.4 This
suggests that traditional methods
of performing shoulder exercises in
supine and/or prone positions may
need to be reconsidered. In some
cases, patients may need to begin in a
seated position. This is recommended
for patients with inadequate balance
or those who are in the early postop-
erative phases of recovery who may
be using opioid pain medication.
Controlling Protraction and
Exaggerating Retraction
Excessive scapular protraction
does not allow optimal rotator cuff
activation to occur. The muscles re-
sponsible for performing scapular
retraction can help control scapular
protraction through eccentric con-
trol. When optimized, these mus-
cles can properly maintain scapular
stability, thus decreasing excessive
protraction with arm movement. A
basic exercise to use in this phase
would be conscious correction of the
scapula using visual feedback.
104
Scapular strength and motion is
best achieved with active scapular
movement performed by the patient.
To optimize arm function, the active
“setting” of the scapula (more com-
monly known as conscious correction)
in a position of retraction has been
advocated as the initial step in reha-
bilitation.5 Most clinicians have used
“scapular squeezing” as an exercise,
but experience has shown that little in-
struction beyond “squeeze your shoul-
der blades together” is conveyed to the
patient. It is common for patients to
“shrug” or simply be unable to per-
form this maneuver correctly, forcing
clinicians to closely monitor the mo-
tion for potential errant movements
(Figure 3A). It is possible that patients
struggle with performing conscious
scapular correction properly because
the free moving scapula is mostly
characterized by accessory motion (ie,
involuntary motion) while also being
posteriorly located and therefore un-
seen by the eyes.
Visual acuity is the strongest type
of feedback humans use for knowl-
Figure 2. (A) Traditional row with
body stationary. Kinetic chain
C row (B) beginning with trunk and
knee flexion and (C) moving to a
fully erect position.
edge of results, knowledge of perfor-
mance, and overall motor control. It
is possible that the scapular motion
alterations seen by clinicians dur-
ing arm movement such as upper
trapezius hyperactivity and vertical
translation of the scapula, as well as
the inability to properly place the
scapulae in a position of retraction
during conscious correction, could
be due to the inability of the patient
to see the scapula moving. Although
adult patients can benefit from ver-
bal external feedback provided by the
clinician, there is a balance between
too little and too much feedback that
must be defined. Too little feedback
does not inform the patient of oc-
curring motion errors, whereas too
much feedback creates a dependency
of the patient on the verbal feed-
back, not allowing learning to occur.
Supplemental equipment that could
assist patients with performing con-
scious scapular correction would be
reflective devices including mirrors
or mobile devices that have a self-
portrait function (Figure 3B).
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 PEARLS OF PRACTICE

Early Closed Chain Implementation

Rehabilitation activities based on A B
the kinetic chain have been grouped
into open and closed chain. Typically,
closed chain exercises are implement-
ed early in the rehabilitation process.
The controlled exercise environment,
ability to focus on specific ranges of
motion, and ability to unload the ro-
tator cuff and other tissue around the
scapula make the use of closed kinetic
chain exercise advantageous in early
rehabilitation. These types of exer-
cises are best suited for reestablishing
the proximal stability and control in
the links of the kinetic chain such as
the pelvis and trunk. For example,
if a patient presents with shrugging
during arm elevation, then it can be
Figure 3. Conscious correction (A) with shrug and (B) using visual feedback.
assumed that the lower trapezius and
upper trapezius (secondary upward
rotators) are not working with the
middle trapezius and serratus anterior A B
(primary upward rotators) effectively
enough during the dynamic task to
control scapulohumeral rhythm. A
closed chain exercise such as the low
row (Figures 4A-4B) should be used
because the short lever positioning
in conjunction with the pelvis and
trunk acting as the driver facilitates
lower trapezius and serratus ante-
rior coactivation, which decreases the
activation of the upper trapezius.6
Once the normal activation pattern
of retraction and depression has been
restored, then more challenging exer-
cises can be employed. Open chain
exercises, which generate greater
loads in comparison to closed chain
activities, should be used later in re-
habilitation programs.
Open chain exercises that require
the arm to be maintained in a straight
position throughout a range of mo-
tion and to be further away from the
body (ie, long lever exercises such as
Ts, Is, and Ys) have been shown to
elicit high levels of muscle activity7-9 Figure 4. Low row (A) beginning with knees flexed and hand against the table and (B) end-
ing with the patient standing erect while pushing back against the table.

Athletic Training & Sports Health Care | Vol. 12 No. 3 2020 105
 PEARLS OF PRACTICE

it is also assumed that the greater de-

mands require more effort to be ex-
erted to perform the exercises, which
may conflict with a patient attempt-
ing to establish scapular control. This
could potentially create a situation
where the patient becomes fatigued
early in treatment sessions, which in
turn could cause the patient to use
compensatory movement patterns
during exercise performance. Short
lever exercises allow patients to fo-
cus on the stability function of the
scapula and can often be performed
A B
with greater ease compared to long
lever exercises. Therefore, it is recom-
mended that short lever exercises be
used in the earlier phases of rehabili-
tation. Once these maneuvers have
been mastered and can be performed
at high levels of sets and repetitions
(4 to 5 sets of 10 to 12 repetitions),
then the progressive integration of
long lever exercises can occur.

Working in Multiple Planes

During the functional phase in
the latter stages of the rehabilitation
process, the transverse plane should
be exploited using diagonal and ro-
tation exercises. For example, it has
been shown that scapular rotations
of posterior tilt and external rota-
C D tion, as well as activity of the lower
trapezius, can be increased by simply
Figure 5. (A) Long lever “Y” exercise. Short lever lawnmower exercise (B) beginning with adding trunk rotation to traditional
trunk and knee flexion and (C) ending with patient standing erect while using trunk rotation
to achieve scapular retraction. (D) Combination of long lever exercise with trunk rotation.
stationary exercises such as humeral
external rotation and forward el-
evation (also known as Is)10 (Figure
and by consequence increase the de- ther long lever or short lever exercises 5D). Scapular rotations, although
mands on the muscles (Figure 5A). are acceptable to use in rehabilitation, they move around an axis, actually
Conversely, exercises that are per- but the timing of implementation cross planes of motion and do not
formed with the elbow in 90 degrees may cause different outcomes. Due occur in a linear fashion. This is due
of flexion and/or with the arm close to the physical demands of long le- to the ellipsoid shape of the tho-
to the body (ie, short lever exercises ver exercises, patients may experience rax and the fiber orientation of the
such as rowing, robbery, or lawn- irritation or soreness during or after muscles acting on the scapula. The
mower) elicit lower levels of muscle the performance of the maneuvers complexities of the scapular motions
activity and have decreased demands when they are employed early in the should not be ignored because the
on the muscles (Figures 5B-5C).6 Ei- rehabilitation process. Additionally, patient will ultimately have a less

106 Copyright © SLACK Incorporated


successful outcome. Using various
planes of motion that mimic indi-
vidual patient function would be
recommended.
CONCLUSIONS
Rehabilitation programs for scapu-
lar dysfunction should follow the eval-
uation of scapular dysfunction philos-
ophy, which views the scapula as a link
in the kinetic chain. The complexity
of scapular motion and the integrated
relationship between the scapula, hu-
merus, trunk, and legs suggests a need
to develop rehabilitation programs
that involve all segments working as
a unit rather than isolated compo-
nents. Obtaining mobility early in the
rehabilitation would in turn allow for
more fluid, task-specific movements
to occur. Furthermore, integrating the
legs and trunk more often in the re-
habilitation process (as allowed by the
patient’s impairments and/or injury)
would closely mimic activities of daily
living, sport, and work tasks. The inte-
Athletic Training & Sports Health Care | Vol. 12
PEARLS OF PRACTICE
grated approach could enhance motor J Orthop Sports Phys Ther. 2013;43(1):3-
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6. Kibler WB, Sciascia AD, Uhl TL,
outcomes. Tambay N, Cunningham T. Electro-
myographic analysis of specific ex-
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