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.