Scapular Downward Rotation

Insufficient scapular upward rotation is the primary movement impairment in this syndrome. The scapular position may be downwardly rotated, adducted, abducted, or normal.  This movement impairment may be evident at any point during the range of motion.  Muscle impairments include dominance, shortness, or stiffness of the downward rotator muscles [e.g., rhomboids, levator scapula, latissimus, pec minor/major] and insufficient activity of the upward rotators [e.g., serratus anterior, trapezius], (Sahrmann, 2004).

SYMPTOMS & HISTORY

 ASSOCIATED WITH IMPINGEMENT

  • Pain in the anterior or posterior shoulder or  deltoid areas
  • Pain caused w/overhead activities
  • Patient unable to sleep on affected side

ASSOCIATED WITH TOS   

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

ASSOCIATED WITH INSTABILITY OF GH JOINT

  • Clunking with arm movements or sensation of shoulder slipping out of socket
  • History of dislocation

ASSOCIATED WITH RHOMBOID OVERUSE

  • Pain in rhomboid area or along vertebral border of scapula

ACTIVITIES

  • Weight lifters or heavy laborers
  • Computer keyboard operators
  • String instrument musicians
  • Mothers of newborns
  • Jobs requiring sustained arm positions at 90˚ of shoulder flexion

KEY TESTS & SIGNS

ALIGNMENT AND APPEARANCE

  • Increased slope of shoulder girdle
  • Scapula downwardly rotated; inferior angle closer to spine than root of scapular spine
  • Clavicular angle lower than normal
  • Humerus in abduction, relative to scapula
  • Correction of alignment impairment decreases symptoms if assoc.with tos; distal symptoms may increase with correction of scapular impairment
  • Scapular downward rotation observed w/scapular adduction
  • Vertebral border of scapula is less than 3″ from spine

MOVEMENT IMPAIRMENTS

SHOULDER FLEXION:

  • Scapula does not achieve 60˚ of upward rotation; correction decreases symptoms
  • Inferior angle does not reach midaxillary line
  • Scapula downwardly rotates  during initiation of shoulder  flexion, evident by dpression of  acromion; correction decreases  symptoms

LIFTING OR HOLDING:

  • Unable to avoid scapular downward rotation during lifting or when loads are added to the arm

MUSCLE LENGTH IMPAIRMENTS

BASED ON LENGTH TESTS:

  • Short rhomboid, latissimus, pectoral, levator scap, and scapulohumeral muscles especially deltoid and supraspinatus

BASED ON ALIGNMENT:

  • Long serratus anterior and upper trapezius
  • Short rhomboid and levator

MUSCLE STRENGTH IMPAIRMENTS  

  • (Greatest impairment) mmt serratus weak or long, lower trapezius weak or long
  • Resisted rhomboid rom reproduces pain in rhomboid  when assoc. w/rhomboid overuse

ASSOCIATED SIGNS

ALIGNMENT AND APPEARANCE

  • Heavy arms
  • May have normal resting alignment
  • Large breasts
  • Kyphosis
  • One arm longer than the other
  • Rhomboid muscles more prominent than others

STRUCTURAL VARIATIONS

  • Long arms
  • Thoracic kyphosis
  • Scoliosis

COMMON ACTIVITIES

  • Habit of postural correction adducts scapula
  • Computer keyboard too low
  • Arm rests on chair too low

MOVEMENT IMPAIRMENTS

SHOULDER FLEXION:

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

PALPATION

  • Associated w/impingement:  may be tender over coracromial ligament, bicipital groove, or rotator cuff tendons (suprspinatus)
  • Associated w/tos: may be tender over scalenes and pec minor

SPECIAL TESTS

  • Associated w/impingement:  impingement tests reproduce pain; resisted tests for rotator cuff and biceps may be either strong/weak and painful
  • Associated w/tos:  tos tests may reproduce symptoms
  • Associated w/instability:  may have increased accessory glide at gh joint in any direction

DIFF MVMT & ASSCOC DX 

DIFFERENTIAL SCAPULAR DIAGNOSIS

  • Rule:  if scapular downward rotation is associated with another imairment (e.g. scapular adduction, depression);diagnosis is scapular downward rotation if passive correction of downward rotation alleviates symptoms
  • Scapular depression
  • Scapular abduction
  • Scapular winging or tilting

DIFFERENTIAL PRIMARY DIAGNOSIS

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

ASSOCIATED DIAGNOSES

  • Rotator cuff tendinopathy
  • Shoulder impingement
  • Partial rotator cuff tear
  • Bicipital tendinopathy
  • Supraspinatus tendinopathy
  • Humeral subluxation
  • Tos and neural entrapments
  • Neck pain with or without radiating pain
  • Pain or trigger points in levator scapula , rhomboids, upper trapezius
  • Bursitis
  • Ac joint pain
  • Calcific tendinopathy
  • Thoracic spine pain
  • Long thoracic nerve injury
  • Drooping shoulder
  • Subscapular bursitis
  • Costochondritis
  • Cervical or cervical thoracic junction pain

MEDICAL DX REQ. REFFERRAL

MUSCULOSKELETAL ORIGIN

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

VICERAL ORIGIN

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

SYSTEMIC ORIGIN

  • Gout
  • Syphillis,gonorrhea
  • Sickle cell anemia
  • Hemophilia
  • Rheumatic disease
  • Collagen vascular disease

MOVEMENT TX

SUPINE POSITION

  • Supine flexion to stretch pec major and latissimus dorsi
  • Therapist assisted pec minor stretch
  • Shoulder medial rotation with arm in 90˚ of abduction

PRONE POSITION

  • Assisted scapular upward rotation and abduction until patient can perform it alone

QUADRUPED POSITION

  • Backward rocking with emphasis on upward scapular rotation

STANDING POSITION

  • Patient faces wall and slides arms up wall …shrugs shoulders after shoulders are flexed to 90˚… Continues until shoulders are fully flexed
  • Patient faces wall with arms at maximum shoulder flexion…adducts scapulae to lift arms off wall… Do not allow shoulder depression

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