Scapular Winging and Tilting

The primary movement impairment in this syndrome is excessive scapular abduction.  Muscle impairments are a dominance of scapular abductor muscles (pec major, serratus anterior) and insufficient activity of the scapular adductor (primarily trapezius) muscles, primarily their alignment and appearance. (Sahrmann, 2002)

SYMPTOMS & HISTORY

ASSOCIATED WITH IMPINGEMENT

  • Pain in ant/post shoulder or deltoid area
  • Pain w/overhead activities
  • Unable to sleep on affected side

ASSOCIATED WITH TOS

  • May experience numbness/tingling in hand
  • May experience decreased circulation or feeling of coldness or whole arm falling asleep w/arms overhead
  • Pain in interscapular area, medial arm, forearm and hand

ASSOCIATED WITH INSTABILITY

  • “Clunking” with arm movements or sensation of shoulder slipping out of socket

ACTIVITIES

  • Jobs req. Sustained arm positions at 90 degrees shoulder flexion
  • Swimmers
  • Weight lifters
  • Laborers
  • Kayakers
  • Cross-country skiers

KEY TESTS & SIGNS

ALIGNMENT AND APPEARANCE

  • Inferior angle of scapula protrudes from thorax
  • Vertebral border of scapula protrudes from thorax
  • Correction of alignment impairment decreases symptoms; if assoc w/tos, distal symptoms
  • May increase w/correction of scapular impairment

MOVEMENT IMPAIRMENTS

ASSOC W/WEAKNESS OF SERRATUS ANTERIOR:

  • Pronounced scapular winging noted during arm elevation and during return; correction decreases symptoms
  • May note scapular adduction during arm elevation
  • Scapula will not achieve 60 degrees upward rotation at end-range shoulder flexion/abduction

MOVEMENT IMPAIRMENTS WITHOUT PROFOUND WEAKNESS

  • Winging /tilting of scapula noted only on return from arm elevation; correction decreases symptoms
  • Scapula and humerus move in 1:1 ratio during arm elevation
  • Insufficient scapular posterior tilt at end-range arm elevation; correction decreases symptoms

LIFTING AND HOLDING

  • Unable to maintain proper scapular alignment (winging/tilting) during lifting or when loads are added to arm
  • Assoc w/weakness of serratus anterior

IMPAIRMENTS IN STRENGTH

  • Weak/long/paralyzed serratus ant.

IMPAIRMENTS IN MUSCLE LENGTH

BASED ON LENGTH TESTS:

  • Short pec min/maj, sh, biceps
  • Based on alignment:
  • Long lower/middle trap (primarily lower)

ASSOCIATED SIGNS

ALIGNMENT AND APPEARANCE

  • May have normal resting alignment
  • May have downwardly rotated scapula
  • Heavy arms
  • Large breasts
  • Hypertrophy of rhomboid muscles

STRUCTURAL VARIATIONS

  • Long arms
  • Flat thoracic spine (winging)
  • Scoliosis
  • Thoracic kyphosis (tilting)

COMMON ACTIVITIES

  • Sit w/slouched posture
  • Activities req. Reaching forward
  • Assoc w/profound weakness of serratus anterior

IMPAIRMENTS IN LENGTH

  • Based on alignment or passive movement:
  • May develop shortened trapezius, rhomboids; lengthened serratus anterior

MOVEMENT IMPAIRMENTS

  • Shoulder flexion
  • Assoc w/impingement: may have slight end-range limitation; may have painful arc
  • Assoc w/tos:  may have numbness/tingling or other symptoms during arm elevation
  • Assoc w/instability:  may observe increased crease distal to acromiom; may also observe increased prominance of humeral head in axilla

PALPATION

  • Assoc w/impingement:  may be tender over coracromial lig., bicipital groove, rotator cuff tendons (supraspinatus)
  • Assoc w/tos:  may be tender over scalenes/pec minor

SPECIAL TESTS

  • Assoc w/impingement:  tests reproduce pain; resisted test of rotator cuff and biceps for soft tissue diff dx may be strong/weak and painful
  • Assoc w/tos: may reproduce symptoms
  • Assoc w/instability:  may have increased accessory glide at gh in any direction

DIFF MVMT & ASSOC DX

DIFFERENTIAL SCAPULAR DX

  • Scapular downward rotation
  • Scapular abduction

DIFFERENTIAL PRIMARY DX

  • Humeral anterior glide
  • Humeral superior glide
  • Humeral medial rotation

ASSOCIATED DX

  • Rotator cuff tendinopathy
  • Shoulder impingement
  • Partial rotator cuff tear
  • Bicipital tendinopathy
  • Supraspinatus tendinopathy
  • Humeral subluxation
  • Tos and neural entrapments
  • Neck pain w/wout radiating pain
  • Pain or trigger points in rhomboids
  • Bursitis
  • Ac joint pain
  • Calcific tendinopathy
  • Subscapular bursitis
  • Snapping scapulae
  • Cervical or cervical thoracic junction pain
  • Long thoracic nerve injury

MED DX REQ. REFERRAL

MUSCULOSKELETAL ORIGIN

  • Long thoracic nerve palsy
  • Cervical radiculopathy
  • Brachial plexus injury
  • Rotator cuff tear
  • Fracture
  • Oa or ra
  • Glenoid labrum tear
  • Peripheral nerve entrapment
  • Spinal accessory nerve palsy

VICERAL ORIGIN

  • Neoplasms
  • Cardiovascular disease
  • Pulmonary disease
  • Breast disease
  • Abdominal organ abnormality

SYSTEMIC ORIGIN

  • Collagen vascular disease
  • Gout
  • Syphilis and gonnorhea
  • Sickle cell anemia
  • Hemophilia
  • Rheumatic disease

MOVEMENT TX

SUPINE POSITION

  • Shoulder medial rotation keeping the scapulae still
  • Emphasis on stretching pec minor and strengthening lower trapezius
  • Correct abdominal muscle imbalances
  • Assisted pec maj/min stretch

QUADRUPED POSITION

  • Quadruped rocking with emphasis on  allowing thoracic spine to flatten

STANDING POSITION

  • Back to wall perform shoulder flexion and abduction with elbows flexed to 90˚…at end range place hands on head and laterally flex to stretch abdominals

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