The SICK Shoulder
The shoulder blade’s only attachment to the rest of the skeleton is through the acromioclavicular joint, the bone is primarily held in place by the attached and surrounding muscle. Muscles use the scapula for attachment, enabling the flexibility and dexterity of the shoulder. Proper positioning and movement of the scapula is critical for full and normal shoulder range of motion. Abnormal movement of the shoulder blade is known as dyskinesis. The acronym SICK describes the state of shoulder when dyskinesia is present
• Scapula malposition
• Inferior medial border prominence
• Coracoid pain and malposition
• Kinesis abnormalities of the scapula
Type 1: Shortening of the musculature that attaches to the coracoid process. Shortened muscles on the anterior side of the body (pec major and pec minor). In the clinic anterior scapular tilting and likely rounded forward shoulders.
Type 2: Weakness or poor activation of the Lower Trap and Serratus Anterior muscles. (Excessive internal rotation, “winging” of the medial border).
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.
Efficient function requires proper scapula alignment. A Sick scapula will result in Scapular Dyskinesis; (an alteration in the normal position or motion of the scapula).
Dyskinesis appears to be a nonspecific response to shoulder dysfunction. A lot of cases result due to poor muscular coordination. Poor shoulder stability results in abnormal tipping and rotation of the scapula which may result in impingement as the acromion pinches down onto subacromial structures, leading to swelling or even tears.
- Intense, repetitive overhead activity/sport
- Overuse leading to fatigue
- Muscle strain
- Overactive Pec major possibly from unbalanced weight training
Signs and Symptoms
- Shoulder appears dropped or lowered
- Medial border scapular protrusion (winging scapula)
- Arrhythmic hitches and jumps in scapula movement during arm flexion and abduction
- Scapular pain instability and clicking
- Pain at the front, back, or top of the shoulder or down outside of your upper arm
X rays, US, MRI’s are all unable to determine scapula dyskinesis. Thorough patient history and examination is used to accurately assess the underlying cause of scapula dyskinesis. Physical testing will assess the nature of the injury, identifying weak or imbalanced muscles and potentially damaged structures.
Treatment of SICK Scapula is suited to physiotherapy, focus on conservative kinetic chain-based rehabilitation retrains normal muscular activation patterns.
A program for scapular dyskinesia considers all postural components, the patient is guided through the acute phase to recovery and beyond into a maintenance phase. The goal is to restore dynamic scapular control, muscle endurance, and a return to the normal scapula-humeral rhythm.
1. Initial focus is improving pain free range of motion, with such techniques as PNF stretches, mobilisation of the scapula and glenohumeral joint, tape and strapping, dry needling, and massage. Exercises in this phase focus on awareness and gaining conscious control of the scapular muscles.
2. Once muscle awareness and control is achieved, general scapular strengthening exercises begin using isometric exercises in simple planes of movement , progressing to more complex multi-planar movements through range.
3. Once muscle control is adequate for daily activities, exercises using combined planes of movement to train proprioception and regain integration and coordination are used. This phase is more functional or sports specific.
Whether dyskinesis is adaptive or pathologic is not known. Scapular dyskinesis can exist in asymptomatic individuals. In symptomatic patients with pain, scapular rhythm should be evaluated and treated. When a patient has an underlying pathology the dynamics of the scapular movement should be evaluated and treated if altered.
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