The SICK scapula in Scapular dyskinesis!

The term Scapular dyskinesis [Dys=alteration; kinesis=motion] aptly refers to loss of control of normal scapular physiology, mechanics, and range of motion (ROM). Scapular dyskinesis (SD) is often confused with scapular “winging” in which altered ROM is attributable to a neurological compromise. This can be clinically detected when the dynamic arm movement examination is conducted. The physical therapists may notice a medial or inferio-medial border prominence of the scapula or an early scapular elevation or shrugging (upon arm elevation), and/or rapid downward rotation (upon arm lowering). The SD is best explained by the theory of altered coupled glenoid and humerus relationship. Specifically speaking, an over-activation of the superior trapezius with under-activation of the inferior trapezius and serratus anterior muscles are noted. The existing evidence reported that, approximately 68%-100% of individuals suffering from a known shoulder pathology present with noticeable SD. The large group of cases (around 80%) report complaints of shoulder pain which is coupled with the lack of ability to do everyday tasks. Overhead athletes have a higher prevalence of SD (upto 60% as compared to non-overhead athletes). The pain is always insidious and often located in the anterior shoulder region. The acronym SICK can be used to describe to the syndrome associated with scapular dyskinesia. The “SICK” Scapula Syndrome refers to Scapular malpositioning, inferio-medial border prominence, Coracoid pain, and malposition and Dyskinesis of scapular movement. The SD associated with clinical symptoms results from patho-anatomy in roughly 1/3^rd of the cases. The examining physical therapist may note that, an absence of demonstrable patho-anatomy is common, and should not misdirect the examiner.

The near differentials to be named for SD are difficult as almost all the shoulder pathologies are associated with some degree of dyskinesis and pain. The most frequent pathologies that are accompanied with SD are acromioclavicular instability, shoulder impingement, rotator cuff trauma, glenoid labrum injuries, and clavicle fracture. Some neurological disorders may pose similar presentations. Thus, an ideal testing sequence and careful diagnosis may be needed for SD. The physical examination manoeuvres are often performed to diagnose SD. These include the scapular assistance test (SAT), scapular retraction test (SRT), lateral scapular slide test (LSST), isometric scapular pinch test, and the wall pushup test. It must be emphasized that, it is critical to assess a patient’s baseline active ROM and pain levels prior to starting the SAT test. Following the baseline assessment, scapular kinematics is assisted by manually providing the scapula with upward rotation while the patient elevates the upper extremity. A positive test must be noted when there is an increased ROM or reduced pain.

The recent evidence in this area had pointed to re-testing and re-consideration of treatment modalities. The evidence-based reviews suggest an algorithm consisting of 3 stages for qualitative assessment of SD. The first is to demonstrate the presence or absence of dyskinesis, using the scapular dyskinesis test.The second is to validate the relationship between the observed dyskinesis and the clinical symptoms using the corrective manoeuvres, the Scapular Assistance Test, and the Scapular Retraction Test. The third is the assessment of the potential causative factors, using a step-wise evaluation process and standard testing.

Considering the intervention, they must be aimed at reducing posterior capsule and pectoralis minor restriction simultaneously restoring periscapular balance through exercises. This must also promote early and increased serratus anterior, lower and middle trapezius activation while minimizing upper trapezius activity. The standard of care for the management of SD is conservative interventions aimed at optimizing scapular kinematics, and surgical intervention is only considered in the presence of concomitant pathology that demands surgery. Conservative treatment can be divided into two subcategories, namely - exercises aimed at improving flexibility, and those focused on increasing scapular stabilization. Combining these two approaches leads to decreased scapular traction and optimizes scapular kinematics. The broad segment of the so-described treatment falls under ‘Rehabilitation of musculature’. This may be given under 3 stages namely, a) active conscious control, b) strength and control for daily activities, and 3) control in athletic performance. The average prescribed duration of such programs is 12 weeks with satisfactory functional outcomes. However, the volleyball players or athletes may need longer programs up to 3 months.

To conclude, SD is a motion and position associated with various shoulder pathologies. Due to significant variation in clinical classifications and dearth of standardized diagnostic methods, it remains difficult to evaluate SD in the clinical setting. The gold standard for treatment is targeted physical therapy which may be given as per standard protocols and based on the necessity of the patient.