Scapular Depression

The primary movement impairment in this syndrome is insufficient scapular elevation.  Initial scapular alignment may be depressed with a failure to elevate sufficiently during movement, or scapular alignment may be normal. Depression occurs during arm elevation.  Muscle impairments include dominance, shortness, or stiffness of the scapular depressor muscles [e.g., latissimus, pecs, lower trapezius], and insufficient activity or lengthened scapular elevator muscles [e.g., upper trapezius and possibly levator scapula]. (Sahrmann, 2002)

SYMPTOMS & HISTORY

ASSOCIATED WITH IMPINGEMENT

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

ASSOCIATED WITH TOS

  • Numbness/tingling in hand possible
  • Decreased circulation/coldness or arm falling asleep w/arms overhead
  • Pain in interscapular area, medial arm, forearm and hand

ASSOCIATED WITH UPPER TRAPEZIUS STRAIN

  • Pain in upper trap area
  • May be associated w/neck pain and headaches

ASSOCIATED WITH INSTABILITY

  • “clunking” w/arm movements or sensation of shoulder slipping out of socket

ACTIVITIES

  • Weight lifters/heavy laborers
  • Computer keyboard techs
  • String instrument musicians
  • Mothers of newborns
  • Women in jobs req. Lifting
  • Ballet dancers
  • Gymnasts
  • Jobs req. Sustained arm positions at 90 degrees shoulder flexion

KEY TESTS & SIGNS

ALIGNMENT AND APPEARANCE

  • Slope of shoulder girdle increased
  • Scapulae lower than t2-t7
  • Neck appears long
  • Clavicular angle lower than normal
  • If unilateral, one arm appears longer than the other
  • Correction of alignment impairment decreases symptoms…if assoc/w tos, symptoms may increase

MOVEMENT IMPAIRMENTS

  • Shoulder flexion:  insufficient scapular elevation…correction of depression decreases symptoms
  • Lifting or holding:  patient unable to maintain correct scapular elevation during lifting or when loads are added to arm

MUSCLE LENGTH IMPAIRMENTS

  • Based on alignment:  long upper trap, levator scap
  • Based on length tests:  short lat, pecs

MUSCLE STRENGTH IMPAIRMENTS

  • Weak/long/strained upper/middle trap

Associated Signs

ALIGNMENT AND APPEARANCE

  • May have normal resting alignment
  • Large breasts
  • Heavy arms

STRUCTURAL VARIATIONS

  • Long arms
  • Long neck
  • Long trunk
  • Short arms

COMMON ACTIVITIES

  • Habitual depression of shoulder girdle
  • Computer keyboard too low
  • Armrests on chair too low

MOVEMENT IMPAIRMENTS

  • Shoulder flex assoc/w impingement:  may have slight end-range limit/painful arc
  • Shoulder flex assoc/w tos:  may have numb/tingling or other tos symptoms during arm elevation
  • Shoulder flex assoc/w instability:  may observe increased crease distal to acromiom…may observe increased prominence of humeral head in axilla

PALPATION

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

SPECIAL TESTS

  • Assoc/w impingement:  tests reproduce pain…resisted tests of rotator cuff/biceps for soft tissue diff diag may be strong/painful or weak/painful
  • Assoc/w tos:  may reproduce symptoms
  • Assoc/w instability:  may have increased accessory glide at gh joint in any direction
  • Assoc/length impairments:  short lower trap/lat

DIFF MVMT & ASSOC DX

DIFFERENTIAL SCAPULAR DX

  • Rule: if scap dep is assoc/w another scap movement impairment. Scap dep is is the dx if passive correction of dep alleviates symptoms
  • Scapular downward rotation
  • Scapular abduction
  • Scapular wing/tilt

DIFFERENTIAL PRIMARY DX

  • Humeral ant glide
  • Humeral inf glide
  • Humeral sup glide
  • Cervical rot
  • Cervical ext
  • Cervical rot and ext

ASSOCIATED DX

  • Rotator cuff tendinopathy
  • Shoulder impingment
  • Partial rotator cuff tear
  • Bicipital tendinopathy
  • Supraspinatus tendinopathy
  • Humeral subluxation
  • Tos and neural entrapments
  • Neck pain w/wout radiating pain
  • Pain/trigger pts in levator scap,rhomb, upper trap
  • Bursitis
  • Ac joint pain
  • Calcific tendinopathy
  • Subscapulr bursitis
  • Snapping scap
  • Drooping shoulder
  • Long thoracic nerve injury
  • Cervical or cervical/thoracic junction pain

MEDICAL DX REQ. REFERRAL

MUSCULOSKELETAL ORIGIN

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

VICERAL ORIGIN

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

SYSTEMIC ORIGIN

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

MOVEMENT TX

MAIN FOCUS

  • Probable lack of physical activity suggests chronically underused and underdeveloped shoulder muscles
  • Shoulder shrugging before lifting or holding and after lifting or holding
  • Shoulder flexion with shrugging
  • Just about any/all shoulder development exercises performed with appropriate shoulder stabilization

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