Exploring Shoulder Blade Problems - The Different Types of Scapular Dyskinesia

Medically, the shoulder blade is called the scapula, and it has a huge range of motion. When it works well it helps support the ball and socket of the shoulder through the full range of motion. The main reason the arm can be placed on your head or behind your back and still work well for eating is that the scapula’s large range of motion helps your get there. When the scapula is not moving normally, we use two fancy terms: “scapular dyskinesia” or “scapular dysfunction” to describe the problem.

These terms refer to a condition where the patient is presenting with abnormal mobility or function of the scapula (shoulder blade). Sometimes the abnormal motion is very subtle, while other times you can see it with the naked eye. Similarly, it can be relatively painless (asymptomatic) or painful in nature (symptomatic). Sometimes it can be noisy and make clicking, crackling or popping sounds. Treatment is usually advised for patients whose dysfunction is coupled with painful and motion limiting symptoms.

In some patients, making noise with the abnormal motion has become a “party trick” and they will ask you to place your hand on the bad part of their shoulder and feel it to confirm they are not crazy.

Abnormal scapular motion comes in a few different forms and should be managed based on the surrounding condition, so in today’s blog, we take a closer look at the different types of shoulder blade problems (scapular dyskinesia) and the management options.

Inferior Dysfunction

Inferior Dysfunction is the first type of scapular dyskinesia, and it is typically a “winging” of the shoulder blade. The shoulder blade ends up rotating forward and the back edge sticks out, oftentimes impinging the top of the shoulder. The person raises their arms in front of their body and one side sticks out. This is seen when standing behind the person with the problem. Many times, when they drop their arms to their sides it seems to go away. 

The reason for this scapular tilt can be traced back to a few causes, including lower and middle trapezius weakness, rotator cuff injury or weakness, and serratus anterior muscle weakness. These muscles help the shoulder blade rotate upward and hold the back edge of the shoulder blade close to the chest wall when reaching our arms overhead. Sometimes it’s a result of a tear of the subscapularis (one of the four rotator cuff muscles) or damage to a nerve that goes to those muscles (the long thoracic nerve).

• Treatment - This type of scapular dyskinesia oftentimes responds well to physical therapy or a training program that strengthens the supportive muscle groups in the area. If it fails to improve then testing for a cuff tear or a nerve injury is needed to find the root of the problem.

Medial Dysfunction

Medial dysfunction occurs when the border of the shoulder blade that is closest to the spine begins to tilt toward the ribs. Some people can demonstrate this to you by making a sound or grinding sensation (the party trick noted above). This medial rubbing can be caused by an injury to the shoulder, shoulder blade or the muscles around it. It can be caused by a thickening or a bump on the edge of the scapula. I have even seen a small benign bone tumor called an osteochondroma do this.

The same muscle issues that define inferior dysfunction can cause medial dysfunction. It is most often caused by weakened or damaged trapezius muscles. Your middle and lower trapezius muscles are crucial for helping provide mobility to the shoulder blade. If weakness and instability set in, so too can medial dysfunction dyskinesia. The real problem here (as I tell all my patients) is that there is a tendency to make the blade rub on the chest wall to make it “feel better.” This is the same as scratching a mosquito bite. It feels good for a few minutes then it’s much worse later. In many cases we cannot get rid of it until we stop scratching the itch!

• Treatment - Targeting this specific muscle weakness is key to realigning the scapula and restoring normal motion in the area. Specific physical therapy exercises that improve the health of the trapezius muscles are typically recommended. The patient must stop the motion that makes the noise or it will never go away completely.

Superior Dysfunction

The final type of scapular dyskinesia that we’ll spotlight is superior dysfunction, and it is categorized by excessive shoulder lifting or “shrugging” of the scapula to compensate for limited upward motion. These patients have to lift or shrug their scapula upward to achieve a fuller range of motion in their shoulder. While muscle weakness is once again usually the culprit (although acute injury can factor in), it’s more about a difference in function between muscle groups in the area. These patients may have healthy large muscle groups, like deltoids, pectorals or latissimus dorsi, and lack strength and stability in the smaller muscles that support the rotator cuff, leading to this abnormal upward shoulder function. Typically, this is seen with a larger rotator cuff tear.

• Treatment - Physical therapy to target the weak rotator cuff muscles is typically the first line of defense. If conservative care fails, an MRI is needed to rule out a rotator cuff tear. Then surgical correction to fix the rotator cuff tear is required.

It is important to remember that some shoulder blade abnormal motion is related to a problem inside the shoulder joint. Prior dislocations, labral tears and chronic instability of the ball in the socket or even shoulder arthritis can also cause the blade to move in odd ways. This makes a lot of sense when you think about it. If the shoulder will come out of place with certain motions and the blade can move that way more “safely” the blade will move first before the ball and socket to prevent the shoulder from popping out of place. This is just mother nature protecting you and is most often seen with patients that are very loose jointed or have had a prior shoulder dislocation. In those cases, a special MRI called and MRI arthrogram is needed to rule out the source of instability.

If you look in the mirror and notice some asymmetry between your shoulder blades, or specific shoulder movements bring discomfort, or a friend sees your scapula winging out under your shoulder when standing behind you, it’s time to set up an appointment with a shoulder specialist and get to the heart of the issue. If you’d rather try to treat any shoulder symptoms on your own, The Knee & Shoulder Handbook, can be a helpful resource. Check it out today on Amazon or Barnes & Noble.

To make an appointment with Dr Reznik or Jaclyn Francis call 203-865-6784. Or email Julie at [email protected].