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
• May experience pain w/overhead activities or reaching forward
• Unable to sleep on affected side
• May be assoc w/thoracic or cervical pain

ASSOCIATED WITH ADDUCTOR STRAIN

• Pain between scapula and spine or along vertebral border of scapula

ASSOCIATED WITH TOS

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

ASSOCIATED WITH INSTABILITY

• Clunking w/arm movementsor the sensation of the shoulder slipping out of socket

ACTIVITIES

• Weight lifters or heavy laborers
• Cellist
• Hairdressers
• Swimmers

KEY TESTS & SIGNS

ALIGNMENT AND APPEARANCE

• Vertebral border of scapula greater than 3 inches from spine
• Plane of scapula is greater than 30 degrees anterior to frontal plane
• Correction of alignment deficiency decreases symptoms; if assco w/ tos distal symptoms may increase w/correction of scapular impairment

MOVEMENT IMPAIRMENTS

• Shoulder flexion:  excessive shoulder abduction; correction of abduction decreases symptoms
• Shoulder flexion:  axillary border of scapula protrudes 1/2 inch or more beyond posterior lateral border of thorax with arm overhead
• Scapula and humerus move in 1:1 ratio
• Insufficient scapular adduction during gh horizontal abduction

LIFTING/HOLDING

• Unable to maintain proper scapular alignment (scap abducts) during lifting or when loads are added to arm

MUSCLE LENGTH IMPAIRMENTS

• Based on length:  short pec maj/min and sh muscles
• Based on alignment:  short serratus anterior, long trapezius and rhomboid

MUSCLE STRENGTH IMPAIRMENTS

• Weak or long trapezius (upper, middle, lower) and rhomboid
• Assoc w/muscle strain, resisted tests of scapular adductors weak and painful

ASSOCIATED SIGNS

ALIGNMENT AND APPEARANCE

• May have normal resting alignment
• Obesity
• Large abdomen
• Large breasts
• Heavy arms
• Thoracic kyphosis
• Hypertrophied sh muscles

STRUCTURAL VARIATIONS

• Long arms
• Thoracic kyphosis
• Scoliosis
• Large or wide thorax
• Common activities
• Habitual abduction of shoulder girdle
• Sit w/slouched posture
• Activities involving reaching forward

MOVEMENT IMPAIRMENTS

SHOULDER FLEXION

• Assoc w/impingement:  may have slight end-range limitation
• Assoc w/tos:  may have numbness or 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

• May be tender over adductor muscle bellies if strained
• Assoc w/impingement:  may be tender over coracoacrmio lig., bicipital groove,or rotator cuff tendons (supraspinatus)

SPECIAL TESTS

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

DIFF MVMT & ASSOC DX

DIFFERENTIAL SCAPULAR DIAGNOSIS

• Scapular downward rotation
• Scapular depression
• Scapular winging and tilting

DIFFERENTIAL PRIMARY DIAGNOSIS

• Humeral anterior glide
• Humeral superior glide
• Humeral medial rotation
• Gh hypomobility
• Cervical extension

ASSOCIATED DIAGNOSES

• 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
• Thoracic pain
• Costochondritis
• Teres syndrome
• Sternal pain
• Cervical or cervical thoracic pain

MED DX REQ. REFERRAL

MUSCULOSKELETAL ORIGIN

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

VICERAL ORIGIN

• Neoplasms
• Cardiovascular disease
• Pulmonary disease
• Breast disease
• Abnormal organ pathologic condition

SYSTEMIC ORIGIN

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

MOVEMENT TX

MAIN FOCUS

• Main focus would be on stretching the short gh and th muscles and improving the performance of adductor component of lower and middle trapezius
• Stretch pec maj/min…

QUADRUPED POSITION

• Stretch humeral rotators int/ext rotation in supine position with hand weights

STANDING POSITION

• Stretch/strengthen serratus anterior and stretch sh muscles
• Patient faces wall and slides arms up the wall – at end of range adduct scapulae avoiding scapular depression
• Progress to patients back to wall – increasing weight of arms – finally to prone position (same motion)