Scapular assessment and its place within clinical reasoning   January 1st, 2015

Scapular dyskinesia has been widely accepted in the literature as associated with glenohumeral joint pathology. Clinicians who manage patients with shoulder pain need to have the skills to assess static and dynamic scapular positioning. At this point, clinicians can use reliable (and valid) clinical tests for the assessment of both static and dynamic scapular positioning in patients with shoulder pain. However, the presence of scapular dyskinesia does not imply a causal association with shoulder pain. Until now, it has not been proven that scapular dyskinesia is either the cause or the effect of shoulder pain. Although the question of causality has its merit in preventive strategy development, it’s of less use to the clinician who works with a shoulder pain patient presenting with scapular dyskinesia. In addition, the presence of scapular dyskinesia does not directly imply an association with the patients’ shoulder pain. This is where the use of symptom alteration tests proves their usefulness, in which the connection is laid between the patients’ specific symptoms and a modifiable factor around the shoulder. Patho-anatomic shoulder tests are criticized for their low diagnostic accuracy, but its use may still be interesting when applied in combination with symptom alteration tests. In addition, scapular symptom alteration tests prove their benefit by providing immediate cues for steering rehabilitation strategies. This is a clear example of an assessment strategy that emphasizes the search for associated dysfunctions, rather than pathologizing the patient. However, one must be cautious when labeling the patient as having scapular dyskinesia. Scapular dyskinesia should not evolve into a second-generation pathology, replacing for instance the impingement mechanism, but rather as just one of the possible dysfunctions contributing to the patients’ complaint. Scapular assessment and rehabilitation should therefore be seen within the general picture of clinical reasoning. There is indeed evidence that prognoses of shoulder pain are negatively altered by more then movement impairment or pain severity alone. Other modifiable prognostic factors enhancing chronification of shoulder pain are both psychosocial factors and lifestyle factors. In addition, neurophysiological factors may contribute to shoulder pain. All these factors are correlated with each other, and in turn, affect each other. Clinically assessing the shoulder should therefore include analysis of psychosocial factors (such as pain catastrophizing), analysis of neurophysiological factors (such as central sensitization), lifestyle factors (such as activity levels or diets) and last but not least movement related impairments (such as scapular dyskinesia). The interaction of all of these factors could produce a meaningful prognostic indicator for the patient and guide further therapeutic options.

For the complete presentation on scapular assessment and its role within the clinical reasoning in patients with shoulder pain, visit the Virtual Shoulder Congress: Virtual Shoulder Congress. Other speakers are: Dr. E. Hegedus, Dr. A. Cools, A. Meakins, Dr. J. Lewis, Dr. M. Margarey and J. Gibson!

Filip Struyf