Scapulothoracic Disorders and Nonsurgical Management of the Impingement



Patients with shoulder impingement often show abnormal scapulothoracic motions known as scapular dyskinesis. In those patients, pain relief with scapular assistant maneuver is a good indication for exercises correcting the scapular dyskinesis and strengthening periscapular muscles. Several clinical studies have demonstrated the effect of scapular exercise programs on reducing pain in patients with impingement. Based on the classification of scapular dyskinesis, optimal scapulothoracic exercises are prescribed. Types 1 and 2 of scapular dyskinesis are observed in patients with subacromial impingement, whereas type 3 dyskinesis is seen in patients with posterosuperior impingement. For type 1 dyskinesis characterized by scapular anterior tilt, stretching of the pectoralis minor and strengthening the lower trapezius and serratus anterior are recommended. For type 2 dyskinesis characterized by scapular internal rotation, strengthening the entire serratus anterior is advocated. For type 3 dyskinesis characterized by scapular elevation and upward rotation, relaxation of the upper trapezius can be an effective intervention. Factors affecting scapular kinematics, such as poor posture and glenohumeral internal rotation deficit, also need to be treated.


Scapulothoracic dyskinesis Scapular dyskinesis Scapular winging Subacromial impingement Posterosuperior impingement Internal impingement Scapulothoracic exercise 

Supplementary material

Video 13.1

Scapular assistance test. For elevation of the right shoulder, the examiner puts his right thumb on the medial aspect of the patient’s scapular inferior angle and puts his left palm on top of the shoulder. To assist scapular upward rotation and posterior tilt, the examiner pushes the inferior angle laterally and anteriorly and pulls the top of the shoulder posteriorly during arm elevation. (MP4 3873 kb)

Video 13.2

Scapular correction in SSMP: elevation, retraction, and posterior tilt. The examiner sequentially corrects the patient’s scapular position during shoulder abduction. First, the examiner elevates the patient’s scapula. Second, the examiner retracts the scapula. Third, the examiner tilts the scapula posteriorly. Then, the examiner asks the patient which scapular correction reduced the symptom most. (MP4 9700 kb)

Video 13.3

Thoracic correction in SSMP. The patient pushes his sternum supero-posteriorly to extend his thoracic spine during arm elevation. Then, the examiner asks the patient if there was any change in shoulder symptom during arm elevation before and after thoracic correction. (MP4 2719 kb)

Video 13.4

Pectoralis minor stretching. The patient lies in supine position. The therapist flexes the patient’s elbow maximally and flexes the shoulder by 30°. Then, the therapist pushes the elbow supero-posteriorly so that the origin and insertion of the pectoralis minor would be separated maximally. (MP4 5556 kb)

Video 13.5

Antigravity flexion in the quadruped position. The patient flexes the shoulder with a light dumbbell in the quadruped position. Simultaneously, the patient needs to keep the positions of the trunk and lower extremities. (MP4 4543 kb)

Video 13.6

Serratus punch. The patient flexes both shoulders up to 90° with the elbows extended in standing position. While the patient is grasping a rubber band with the involved hand (left hand) and the therapist pulling the rubber band from behind, the patient retracts the scapulae bilaterally and then protracts them maximally. To keep the neutral rotation of the trunk, the patient needs to perform symmetric motion of bilateral scapulae. (MP4 1297 kb)

Video 13.7

Lawn mower exercise. The patient begins this exercise with a contralateral leg stepped forward and with a flexed and rotated trunk toward the contralateral side with the hand in front of the stepped leg. Then the patient rotates and extends the trunk while retracting the scapula. (MP4 4284 kb)


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Copyright information

© ISAKOS 2019

Authors and Affiliations

  1. 1.Department of Orthopaedic SurgeryTohoku University School of MedicineSendaiJapan

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