Scapular Assistance and Scapular Resistance Tests
Dr. Benjamin Kibler and others have taught us that scapular dyskinesis and poor scapulothoracic control is extremely common in symptomatic overhead athletes, but also commonly associated with impingement syndrome, labral tears, and rotator cuff problems for the general population. Improved scapular positioning with scapular retraction and posterior tipping with arm elevation is commonly not addressed sufficiently in rehabilitation programs and should be part of shoulder rehabilitation programs. Improved scapulothoracic motion and scapular control is also important for patients with osteoarthritis and total shoulder arthroplasty rehabilitation.
The Scapular Assistance Test (SAT) popularized by Dr. Kibler is performed by assisting the scapula’s upward rotation and posterior translation with positive relief of external impingement symptoms and improved range of motion. The Scapular Resistance Test is performed while actively or passively positioning the scapula into an appropriate position (of retraction) with increased rotator cuff strength and relief of internal impingement symptoms to manual testing.
The Scapular Assistance and Scapular Resistance Tests evaluate function and neuromuscular interaction of the shoulder girdle and are extremely helpful to show the patient that improved scapular (proximal) control may alleviate pain and dysfunction helping to improve rehabilitation compliance. Evaluating the shoulder girdle as part of the physical examination allows the examiner to put the scapula in context to the shoulder dysfunction and impairment, pain, and symptoms of the patient. This allows important identification of rehabilitation corrections including altered positions, muscle tightness or inflexibility, and/or muscle weakness or imbalance.
The shoulder examination should include not only examination from the patient’s front but visualization from the back allowing one to examine and see the dynamic positioning of the scapula during forward elevation and abduction. This allows for identification of scapular dyskinesis and upper trapezial tightness with inhibition or weakness of the lower trapezius and serratus. Tenderness, muscle strength, ROM, joint mobility, impingement and instability tests should also be routinely checked.
The physical examination is important in evaluating cervical head forward position, trapezial tightness, scapular protraction, height, and appropriate positioning, and scapulothoracic mobility as well as range of motion of the shoulder joint. A realization that scapulothoracic motion is responsible for one third of the motion to lift the arm overhead necessitates evaluation of scapulothoracic rhythm when evaluating shoulder pathology. If one only thinks of impingement syndrome and rotator cuff pathology as inherent to shoulder joint motion and not scapulothoracic motion, nonoperative and operative surgical results will not address many of the issues that cause the impingement syndrome and rotator cuff tear/pathology in the first place.
A useful teaching analogy for patient education on shoulder function is likening rotator cuff tears, impingement syndrome and deltoid pain to car alignment issues leading to uneven tire wear. With significant car alignment issues, just changing tires will not prevent future uneven tire wear and both appropriate alignment and tires need to be corrected for efficient functioning of one’s vehicle. This is analogous to only focusing on rotator cuff strengthening without regard to scapular positioning and motion which will not adequately address the majority of shoulder problems.
