SICK Scapula: An Overlooked Cause of Shoulder Pain
SICK scapula or shoulder dykinesis is a form of shoulder pain created by disorganized movement of the shoulder joint.
Kinesis refers to “motion”, and the prefix “dys” describes something that is “bad, abnormal or difficult”.
In the case of SICK scapula, individuals who repetitively use their arms for overhead motion such as throwing, swimming or swinging a racquet, are all at risk of developing this condition.
Pain may be followed by limited range of motion, and if left untreated, may develop into a more severe shoulder injury.
This article will help explain the anatomy of the shoulder, the features of SICK scapula and the treatments that can be used to correct it.
Inferior medial scapular winging
dysKinesis of the scapula
9 Clinical Pearls
- The collar bone or clavicle is the only bone holding the shoulder to the skeleton
- Proper shoulder blade or scapular positioning allows the shoulder to do what it is supposed to do
- Common dysfunctions start with scapular or shoulder blade winging appearance
- Most common symptom is pain (duh!)
- Tight pecs are a precursor to shoulder injuries and poor scapular motion
- Another common symptom is having one shoulder lower than the other
- Shoulder dysfunction is often found with upper crossed syndrome (poor computer posture) Upper Cross Syndrome
- Poor scapular function leads to rotator cuff and labral tears of the shoulder, especially with quick athletic movements
- 8-12 weeks of regular rotator cuff exercises, stretches and scapular rehab can prevent shoulder injuries (shoulder rehab video)
The Anatomy of the Shoulder
The scapula, more commonly referred to as the shoulder blade, is the boney structure on the upper back below the top of your shoulder and just behind the axilla.
It is a free floating structure with only one attachment to the upper body through a joint located at the end of the clavicle (or collar bone) called the acromioclavicular joint.
The long bone of the upper arm, called the humerus, sits in a small socket on the outer edge of the scapula. It is called the glenohumeral joint.
The glenohumeral joint by itself has very little stability. It relies on a set of four muscles known as the rotator cuff to provide the foundation and stability of the shoulder.
The rotator cuff muscles and their functions are as follows:
- Supraspinatuswhich predominately stabilizes the shoulder and helps elevate the arm away from the body (abduction), this is also the most commonly injured.
- Infraspinatuswhich helps rotate the upper arm so the palm faces up (external rotation)
• Teres minor which also aids in external rotation
• Subscapularis which helps rotate the arm so the palm faces down or out depending on the starting position of the arm
In addition to the rotator cuff, there are several other muscles that are involved in shoulder stabilization and range of motion.
These muscles can also be involved in SICK scapula:
- Trapeziuswhich help pull the scapula toward the spine (scapular retraction), upward as if “shrugging” the shoulders (scapular elevation), and down and inward toward the midback (scapular depression)
- The rhomboidswhich also aid in scapular retraction
- Levator scapulawhich also aid in scapular elevation
- Serratus anteriorwhich stabilize the scapula and pull the scapula away from the spine as when the shoulders roll toward the front of the body (protraction/scapular abduction)
- Pectoralis majorwhich helps pull the arm towards the body (adduction)
How SICK Scapula Happens
Because the shoulder is capable of such a wide range of motion, a very complex and harmonious chain reaction of muscle contraction must occur for normal, painless movement.
For those who repetitively use the shoulder in strenuous overhead activity, weakness and instability in any part of that chain reaction can lead to injury.
This can also be true of people who sit at a desk all day and develop rounded shoulders from bad posture.
SICK scapula can be both a precursor to injury and the result of a previous one.
Like the parts of an engine, the muscles of the shoulder must all work together perfectly.
The repetitive overhead use causes certain muscles to weaken while others tighten.
This pulls the scapula away from the body, tilting and rotating out of its normal plane of movement. In turn, this puts stress on the head of the humerus as the angle of the glenohumoral joint changes.
Pain and restricted motion of the arm are the result.
Eventually, the normal, smooth movement of the scapula becomes completely distorted due to its altered position. In this state, continued intense, repetitive use greatly increases the chance of severe injury.
Therefore, if there is pain through range of motion or with exertion, it can be important to consider this diagnosis in addition to shoulder strain, as both share common characteristics, but have very different underlying causes.
SICK scapula is a biomechanics problem, while shoulder strains are muscle damage due to intense, repetitive movements that apply too much pressure to the muscle and joint.
Athletes such as swimmers, tennis players, baseball players and softball players are susceptible given the nature of their sports.
SICK Scapula Symptoms and Evaluation
Pain and limitation of shoulder movement are usually the main complaints.
Because the scapula is misaligned, the affected shoulder will appear lower than the other or “dropped”. Also, the scapula will appear “winged” or protracted due to its altered position.
The top, front or outer portion of the shoulder may be painful to the touch.
A functional assessment tests for pain, strength and range of motion. It is very useful in diagnosing this condition. Imaging tests can be used if there is a history of shoulder trauma to rule out any fractures. Imaging can also help identify joint degeneration, bony impingement of the soft tissues and arthritis.
If a muscle strain is suspected, a musculoskeletal ultrasound can be used to evaluate for scar tissue, as this can also be a source of restricted shoulder movement and pain.
Treatment for SICK Scapula
The good news is there are many therapeutic options for treating SICK scapula.
The foundation of any program will most likely include RICE (Rest, Ice, Compression and Elevation) in addition to NSAIDs such as ibuprofen or naproxen.
Physical therapy, physiotherapy or working with an experienced strength and conditioning coach are all good options. These practitioners may also recommend or incorporate soft tissue manipulation techniques such as Active Release Technique or Hawk Grips Therapy .
An important part of any rehabilitation program is stretching. Many individuals fail to recognize the importance of stretching and warming up prior to activity. The presence of scar tissue in the muscle makes it more dense, less flexible and difficult to fully elongate.
Stretching helps get the most out of any strengthening regimen.
The common misconception that a tight muscle is a strong one is not only incorrect- it can lead to injury!
Sometimes, a tight muscle signifies it is weak, in constant spasm to maintain function, and on the verge of greater injury.
In SICK scapula, the pectoralis minor is usually very tight, contributing to the misalignment of the scapula. An effective stretch for this muscle is simply placing the forearm flat on a wall or doorway and then stepping forward.
Stretches such as this should be incorporated into the therapeutic routine.
Eccentric rehabilitative exercises are also very helpful as they focus on strengthening the muscles and tendons involved in SICK scapula. These exercises can stimulate healing within the first six weeks, giving the best prognosis for recovery. Approximately 8-12 weeks of treatment will be needed, depending on the injury.
Steroid injections may be of use in decreasing the discomfort and in some cases, surgery is indicated in order to repair torn muscular tendons.
In summary, it is important to consider SICK scapula when there is shoulder pain. It is a diagnosis that can easily be made in certain individuals who perform overhead activities and have very specific findings on a physical exam.
Most importantly, when recognized early and treated, it can spare further advanced injury.
Dr. Derek Gearhart