Treating a shoulder patient can seem very complex and overbearing at times. This post from the Sports Physiotherapist helps breakdown different scapular dyskinesias to allow for easier diagnosis and treatment of shoulder pathologies.
Reviewing each dyskinesia:
Type 1: Shortening of the musculature that attaches to the coracoid process. In this dyskinesia, muscles are being shortened on the anterior side of the body (pec major and pec minor specifically). In the clinic, you will observe anterior scapular tilting and likely rounded forward shoulders. Treatment options include performing a pec minor release and pec minor stretching. Both of these techniques are demonstrated by Dr. E (the manual therapist), Mike Reinold, and Chris Johnson.
Type 2: Weakness or poor activation of the Lower Trap and Serratus Anterior muscles. In the clinic, if you suspect a type 2 dyskinesia, you will likely see excessive internal rotation, "winging" of the medial border, and anterior scapular tilting. The original post has 6 great videos demonstrating how to elicit these muscles. Exercises that have shown great serratus anterior MVIC include serratus punch and push-up plus. For the lower trapezius performing prone Y's and prone shoulder external rotation is very beneficial. According to McCabe et al, Prone Shoulder External Rotation with the arm positioned at 90 degrees abduction elicited a 79% MVIC.
Type 3: Excessive Superior Border Prominence. These patients often have hypertonicity of the upper trapezius muscle and likely have a poor Upper Trap: Lower Trap muscle firing ratio. From my personal experiences in the clinic, these individuals have excessively tight upper trap muscles, hypomobile first ribs, and complaints of cervical tightness as well. The Sports Physiotherapists recommends performing external rotation in neutral, upper trapezius/ levator scapulae stretching, and joint mobilization to the cervical, thoracic, and scapular regions. Additionally, Arlotta, Lovasco, and McLean found that the Modified Prone Cobra selectively recruited the lower trapezius muscle with relatively low upper trapezius muscle activation.
The original article has great video demonstrations of how to perform each exercise. Check it out!
Arlotta M, Lovasco G, and McLean L. Selective Recruitment of the lower fibers of the Trapezius Muscle. J Electromyogr Kinesiol. 2011. 21.3: 403.410. Web. 27 Feb 2013
McCabe R, et al. Surface Electromyographic Analysis of the Lower Trapezius Muscle during exercises performed below 90 degrees of Shoulder Elevation in Healthy Subjects. N Am J Sports Phys Ther. 2007. 2.1: 34-43. Web. 27 Feb 2013.
3/4/2013 06:25:11 am
Great post. I would also recommend standing bilateral ER for improved lower: upper trap activation. McCabe published a study in 2007 and found a great ratio of L:U activity. Also found 2:1 L:U with the press up which may be good for some if there pec minor isn't already hyperactive/tight
3/4/2013 06:26:27 am
Ha. ER in neutral is bilateral ER. Different terminology we use
3/4/2013 09:42:14 am
Do you guys think it's a problem using static hold/isometric strengthening exercises to address muscle weakness in patients with dyskinesis when the problem by its very nature is associated during active motion of the UE and not just static posture? So, for example, the prone cobra exercise may be good at eliciting a strong contraction of the low trap and minimizing the upper trap contraction but it's only strengthening the scapulothoracic muscles in that one position (+/- ~10 degrees) as opposed to something like a y-raise or t-raise in full ER. Is it such a big deal? Do they both have a place in different phases of rehab?
3/5/2013 11:00:18 am
Zachary and Devin,
8/3/2014 06:58:47 am
owq! You have a nice and very informative blog .
7/3/2015 07:32:10 pm
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