Scapular Dyskinesis Rehabilitation Protocol

This rehabilitation protocol outlines a comprehensive physical therapy approach to managing scapular dyskinesis, a condition characterized by altered scapular movement patterns. The protocol is divided into phases, progressing from pain management and tissue protection to functional restoration and return to activity. Progression through phases depends on individual patient progress, pain levels, and achievement of specific criteria.

Pathophysiology

Scapular dyskinesis refers to an alteration in normal scapular resting position or motion during coupled shoulder movements. It's not a specific diagnosis, but rather a clinical sign often associated with various underlying pathologies. These include:

• Muscle imbalances: Weakness or tightness of scapular stabilizers (serratus anterior, trapezius, rhomboids) or rotator cuff muscles.
• Nerve injuries: Long thoracic nerve (serratus anterior), spinal accessory nerve (trapezius), or suprascapular nerve (infraspinatus, supraspinatus).
• Glenohumeral joint instability or impingement: Altered scapular kinematics to compensate for glenohumeral dysfunction.
• Postural abnormalities: Forward head posture, rounded shoulders.
• Bony abnormalities: Scapular fractures or malunions.

The altered scapular mechanics can lead to shoulder pain, decreased range of motion, and increased risk of shoulder impingement and rotator cuff injuries. Proper scapular stabilization is crucial for optimal shoulder function.

Phase I: Protection and Pain Management (Weeks 1-3)

Goals: Reduce pain and inflammation, restore initial range of motion, initiate gentle scapular stabilization exercises, and educate the patient.

• Pain Management:
  • Rest and activity modification: Avoid aggravating activities.
  • Ice or heat application: As needed for pain relief.
  • Medications: As prescribed by physician (NSAIDs, analgesics).
  • Gentle manual therapy: Soft tissue mobilization to address muscle tightness and improve tissue mobility.
• Range of Motion (ROM):
  • Pendulum exercises: Gentle circumduction and flexion/extension to maintain glenohumeral joint mobility.
  • Scapular clock exercises: Small, controlled movements of the scapula in various directions (elevation, depression, protraction, retraction) within a pain-free range.
  • Active-assisted ROM (AAROM): Using a wand or pulley to assist with shoulder flexion, abduction, and external rotation, focusing on pain-free movement.
• Scapular Stabilization Exercises (Low Intensity):
  • Scapular setting exercises: Consciously retracting and protracting the scapula, focusing on feeling the muscles engage.
  • Isometric scapular retractions: Holding the scapulae together for a few seconds, without any movement.
  • Isometric shoulder external rotation: Pressing the arm against a wall or resistance, engaging the rotator cuff and scapular stabilizers.
• Patient Education:
  • Proper posture: Emphasize maintaining a neutral spine and relaxed shoulder girdle.
  • Body mechanics: Teach proper lifting techniques to minimize stress on the shoulder.
  • Activity modification: Educate on avoiding activities that exacerbate symptoms.
• Criteria for Progression:
  • Decreased pain at rest and with initial movements.
  • Improved active range of motion in pain-free arc.
  • Ability to perform scapular setting exercises without pain.

Phase II: Loading and Strength Restoration (Weeks 4-8)

Goals: Improve scapular muscle strength and endurance, progress glenohumeral strength, and improve neuromuscular control.

• Scapular Stabilization Exercises (Progressive Resistance):
  • Scapular retractions with resistance band: Progressing band resistance as tolerated.
  • Prone rows: Strengthening the rhomboids and middle trapezius.
  • Lower trapezius exercises: Prone T's, Y's, and W's.
  • Serratus anterior punches: Strengthening serratus anterior with resistance band or light weight.
  • Wall slides with resistance band: Encouraging upward rotation and scapular stability.
• Rotator Cuff Strengthening:
  • External rotation with resistance band: Strengthening the infraspinatus and teres minor.
  • Internal rotation with resistance band: Strengthening the subscapularis.
  • Scaption with light weight: Strengthening the supraspinatus and deltoid while maintaining scapular stability.
• Glenohumeral Strengthening:
  • Bicep curls, triceps extensions: Using light weights and focusing on controlled movements.
  • Lateral raises, front raises: Progressing weight gradually, while monitoring scapular position.
• Proprioceptive Exercises:
  • Rhythmic stabilization exercises: Applying manual perturbations to the shoulder while the patient maintains stability.
  • Weight shifting exercises: Shifting weight from one side to the other while maintaining proper posture and scapular control.
  • Use of wobble boards or balance discs: Challenging balance and proprioception.
• Criteria for Progression:
  • Pain-free full range of motion.
  • Good scapular control during functional movements.
  • Improved strength in scapular and rotator cuff muscles (at least 4/5 on manual muscle testing).

Phase III: Return to Function (Weeks 9+)

Goals: Restore functional activities, improve endurance, and prevent recurrence.

• Sport-Specific/Activity-Specific Training:
  • Gradual return to sport-specific drills or work-related tasks.
  • Focus on proper technique and scapular mechanics during these activities.
  • Progressive increase in intensity and duration of activity.
• Advanced Strengthening:
  • Plyometric exercises: Medicine ball throws, push-ups with clap (if appropriate).
  • Isokinetic training: Using isokinetic equipment to further strengthen muscles at various speeds.
  • Overhead activities: Gradual progression to overhead activities with controlled movements and proper scapular control.
• Endurance Training:
  • Performing repetitive movements with light resistance for longer durations.
  • Increasing the number of repetitions and sets as tolerated.
• Maintenance Program:
  • Continue performing scapular stabilization and rotator cuff strengthening exercises regularly to maintain strength and prevent recurrence.
  • Maintain good posture and body mechanics during daily activities.
  • Address any muscle imbalances or postural abnormalities.
• Criteria for Discharge:
  • Pain-free performance of functional activities.
  • Adequate strength and endurance for sport-specific or work-related tasks.
  • Good scapular control during all activities.
  • Patient understanding of home exercise program and strategies for preventing recurrence.

Common Special Tests for Scapular Dyskinesis

• Scapular Assistance Test (SAT): Manually assists scapular upward rotation and posterior tilting during shoulder elevation. A positive test is indicated by decreased pain or improved shoulder range of motion, suggesting scapular dyskinesis contributes to the patient's symptoms.
• Scapular Retraction Test (SRT): The patient actively retracts their scapula while performing painful shoulder movements. A reduction in pain during active elevation with scapular retraction is considered a positive test, indicating a role of scapular instability or malposition.
• Lateral Scapular Slide Test (LSST): Measures the distance between the vertebral border of the scapula and the spine at three positions: arm at side, arm at 45 degrees abduction, and arm at 90 degrees abduction. A difference of greater than 1.5 cm between sides in any position suggests scapular dyskinesis.
• Flip Sign: Observed with the patient in prone, abducting the arm to 90 degrees and flexing the elbow to 90 degrees. Weakness of the lower trapezius and serratus anterior may lead to the inferior angle of the scapula "flipping" off the thorax.