I’ve been reading and listening to probably what is more than a healthy amount of scapular research and rehabilitation lately. It’s great for me because I’m currently working with a few athletes with scapular dyskinesia and shoulder pain. I wrote a bit about scapular dyskinesia some time back and it’s easily one of my most popular articles to date.
Now, it’s important to understand that winging and dyskinesia can happen for variety of reasons. Pain is a huge player in the mix as well as specific weakness or muscle imbalance. As a therapist it’s our job to determine why this winging is occurring and troubleshoot how to correct it. This article is going to talk more about specific weaknesses.
There are also several different types of winging and dyskinesia. Sometimes the inferior border of the scapula pops up with movement (Type 1). Sometimes the shoulder is protracted (scap anterior tilt/internal rotation) at rest (Type 1). Sometimes we get a shrug with excessive downward rotation when we raise our arms overhead (Type 3). What I’d like to talk about today is medial border prominence (Type 2) as shown in the picture above. I see this quite a bit in athletes especially when they’re attempting pushups.
This article’s inspiration comes from Ann Cools. She is a researcher, physiotherapist and professor. She is an absolute boss when it comes to the shoulder and specifically the scapula. The clinical reasoning process used in this article comes from her.
First off, when you see this occur in your patients you have to ask the question of why is this occurring? Dyskinesia could theoretically cause shoulder pain but can also occur because someone is in pain (Maybe an individual is moving differently to decrease stress on a sensitive area in the shoulder). Ultimately we want to promote symmetry between scapulae and normalize motion. Just keep in mind that sometimes we’ll be dealing more with pain and sometimes more with a tightness/weakness/timing issue.
One major reason why you can get this medial border prominence is a specific weakness of either the serratus anterior or the rhomboids (potentially the mid and lower trap as well). These 2 muscles normally stabilize the medial border of the scapula. As a clinician we can perform some manual muscle testing to determine which is the more problematic area.
Is it the rhomboid?
Is it the Serratus Anterior?
Chances are it may be a combination of the two. Also keep in mind that having a weakness of the serratus anterior can come from a palsy of the long thoracic nerve. I don’t see this too often in my clinical practice with fitness athletes but this doesn’t mean it isn’t important. The long thoracic nerve originates from C5-C7 and treatment of this nerve might help with serratus strength. Just make sure you screen the neck in your evaluation.
Once you’ve figured out where the major weaknesses lie it’s time to get after some strengthening. I’m sure you can find plenty of EMG studies by both Cools and research superstar Ben Kibler about the best exercises to address these areas, especially in the early stages of rehab. You’ll also have to teach your patient how to move their scapulae properly. A few nice motor control exercises from Burkhardt’s SICK scapula program (Labeled under Scapular Clock) work well here. I wanted to present a few of my favorite exercises to be used by more advanced athletes in the later stages of rehab. If you’re interested Bret Contreras has done a lot of work with heavy lifting measuring EMG activity and can give some more ideas of which exercises are going to hit the mid and low-trap the best.
Ideally, rehab should consist of both open and closed chain exercises with a specific emphasis on exercises that most closely resemble what the athletes needs to get back to. If your athlete needs to get back to gymnastics activities then closed chain would be more appropriate. An olympic lifter would be better suited toward open chain exercises. Just remember it isn’t appropriate to give your patient a more advanced exercise when they can’t display adequate scapular control as of yet. Phase 1 and 2 in the videos below focus heavily on exercises to address these weaknesses. Phase 3 in the videos are skill/positioning exercises specific to sport.
Closed Chain Exercises:
Open Chain Exercises:
For my patients with a medial border prominence due to specific weakness, these exercises usually work pretty well. Give it a shot with your patients and let me know how it goes!
I Hope I Spelled Dyskinesia Properly,
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