Assessing static scapula position and dynamic motion is an essential step in diagnosing shoulder impingement and instability. Static and dynamic assessment should be considered as two different issues.

In Kibler and Sciascia’s (2010) position statement, if the scapula is positioned poorly statically it should be termed an “altered resting scapular position” and dysfunctional movement of the scapula should be termed "scapular dyskinesis"

While scapular resting position is commonly assessed in painful shoulders it is less common practice to assess scapular dyskinesis. Key assessment observations of scapular dyskinesis in injured patients are a loss of scapular upward rotation, excessive scapular internal rotation and excessive scapular anterior tilt (Ludewig and Cook, 2000). There is also altered recruitment patterns and reduced strength in scapular stabiliser muscles (Smith et al. 2006)

These dysfunctional scapula movements and muscle activation decrease the subacromial space, increasing the risk of impingement and also reduce rotator cuff strength.

It appears that the key players in stabilising the scapula during arm movement, giving the rotator cuff a stable base to work from to “keep the ball in the socket”, are lower trapezius and serratus anterior.  The lower trapezius and serratus anterior work together in a force couple to upwardly rotate the scapula (see Figure 1).

Figure 1. Force coupling - Upper trapezius and serratus anterior

Muscle activation studies have also shown that increased scapular protraction is due to a combination of increased contributions from pectoralis minor and latissimus dorsi.

Rotator cuff activation and biceps fatigue and damage will often follow as these muscles must work harder to compensate for the altered scapula–humeral rhythm that tends to allow the humeral head to migrate away from the glenoid.

The research above clearly advocates that rehabilitation for scapular dyskinesis should start proximally and end distally.

You also cannot effectively strengthen a rotator cuff if the scapular is in a protracted and internally rotated position. Increased thoracic kyphosis, abdominal tension, increased lumbar lordosis, forward head posture all influence the position and length tension balance around the shoulder complex.

If a client presents with proximal issues these must be worked on before or concurrently while working on the scapula/shoulder.

An example of a key technique that I would recommend to improve thoracic positioning is the use of foam roller mobilisation. Figure 2 has the patient lying on the roller longitudinally while twisting the shoulder girdle and hip girdle in opposite directions to mobilise the spine. We have found this non-aggressive technique to be extremely effective in early stage rehabilitation. We would also additional thoracic extension exercises to further mobilise and strengthen the thoracic spine position.

Massage therapy, mobilisation and stretching can all be used to achieve scapular posterior tilt, external rotation, and upward rotation. The scapular must be able to achieve this position for optimal function.

An effective stretch for pectoralis minor is demonstrated in Figure 3.  Retract and depress the scapula while pushing the front of the shoulder joint into the Swiss ball.

Figure 3. Pectoralis minor stretch

Rotator cuff strengthening exercises in rehabilitation should only be incorporated after scapular control is achieved and should emphasise closed chain, humeral head co-contractions (Kibler at al., 2000; Kibler and Sciascia, 2008). Closed chain exercises should precede the use of open chain exercises. If your patient has an increase in impingement pain when doing open chain rotator cuff exercises this indicates that s/he needs more scapula control training before progressing. Scapula control exercises and effective techniques for retraining scapula dyskinesis will be thoroughly covered in the Practical Programming for Exercise Rehabilitation workshop.