My current thought process on fixing Scapular Winging

Since my blog post on shoulder part 1 and 2 that you could read Here and Here, I have received a lot of questions on scapular diskinesia and recommendations on managing it. As I did not really cover it in my previous blog post, this blog post will be dedicated to just that.
Scapular dyskinesia, which means abnormal movement of the scapula can present itself in different forms but most commonly manifests itself as ‘winging’ of the medial or inner border of the scapula. ‘Winging’ means that the inner border of the scapula lifts off the rib cage. This could happen during a simple overhead arm elevation (open kinetic chain) or during an exercise like a pushup (closed kinetic chain).
In an ideal healthy shoulder complex, the scapula and the ribcage work like new lovers; always close to each other and ‘almost’ inseparable. The important task to kindle this romance is primarily bestowed upon the serratus anterior (SA) along with the rhomboids and lower traps. However, sometimes these muscles misbehaves creating some trouble in paradise in this relationship. The serratus anterior is supplied by the long thoracic nerve and on observation of winging in your patient, its prudent to check for some kind of long thoracic nerve issue by doing a neck screening.
However, in my experience if there is no H/O traumatic injury, systemic illness etc that might effect the long thoracic nerve; we might be dealing with an inhibited SA. In the past I would quickly get to work by strengthening SA with some of these classic exercises for strengthening.

1. Theraband SA punches
2. Theraband and pulley Rows
3. PNF for lower traps
4. ‘Y’, ‘T’ exercise.

This strategy could be a hit or a miss. It could work for some deconditioned/older patients who have general muscular weakness and strengthening the SA, rhomboids and lower traps  could fix the problems. Makes sense right. However, very often its a miss. Picture a client who is fit, could perform pushups until the cows come home, and is nowhere close to having muscular weakness but still shows signs of winging with arm elevation or with other CKC exercises. What do we make of this??
What this means to me is that the SA is unable to reflexively hold that medial border and inferior angle down on the rib cage during certain movements. In other words, its unable to provide the stability through the full ROM. It could be either an inhibited muscle unable to generate enough force to hold that shoulder blade down due to bad ribcage-scapula position or maybe a timing issue where its not firing well at certain periods through the ROM or more likely a combination of both. Hard to be exactly sure here.
But the key here is stability. In Human kinetics, I believe this means the ability of the body to hold the correct form through full ROM. And here lies the problem. Almost all the above exercises work on a single plane at about a 90-120 degree of arm in flexion. Hate to state the obvious but are they functional? Will they train the muscles to hold that scapula in a good fixed position on the rib cage in a overhead position in OKC exercises? My experience is mostly negative. How about you?
So where do we go from here? Below are some of the strategies that I have incorporated recently that I find extremely useful and better than the traditional exercises stated above. I demonstrate this in videos below on (1) myself  as I have some left scapular winging with arm elevation and (2) on my colleague and fellow Physio who is involved in competitive dragon boat racing.
In the video below, I do a Dumbell press of 40lbs with a plus (protraction) to demonstrate how my left SA struggles to hold the load compared to my right.
 
 
[wpvideo xKjlXy5x]
Below is a video of me doing an arm elevation test which demonstrates winging and how I correct it.
 
 
[wpvideo 7LlihInd]
By pushing on the wall and protracting my shoulders, I am getting into a ‘locked ribcage’ position and reflexively activating my SA to hold that medial border down by creating a good congruent ribcage shoulder blade position. No theraband exercises to strengthen the muscle might be needed in my case. Just a favorable position for my SA to work reflexively.
Need another example? Sure. My colleague is a perfect example of a candidate who is not weak, in fact she is very strong and trains hard to compete in dragon boat racing. You think she’d have a weak serratus? Or that you could fix her winging with a theraband? I’m sure you know the answer.
 
[wpvideo 1bKuFiVf]
 
Here I must report, she does not have any pain, just C/O weakness. Her winging does not seem to be excessively abnormal, it could be well within a certain normal range of winging which most of us might have but asymmetrical to the other side.
 
Now, I like to be a little more specific depending upon the clients needs when prescribing exercises to tackle scapular instability. To give a few examples, I’d prefer more OKC exercises for swimmers, volleyball players, rowers, cricket bowlers etc and CKC for gymnastics. Often, both as the situation demands. Here are some examples of my preferred exercises-
Closed kinematic chain-

1. Cat Cow

 
 
 
[wpvideo Rk2sH5lI]
 
2.  Quadripod knee lift
 
 
 
[wpvideo QOL8w0YX]
 
3. Plank plus-
 
 
[wpvideo yCjb9ibJ]
 
 
4. Pushup plus
 
[wpvideo z5S05IeA]
 
Open Kinematic Chain exercises-

1. Kettlebell press supine

 
 
 
[wpvideo UU2YVQgK]
 
2. Kettlebell Overhead press- Now for some of my favorites, the press. Another excellent way to fix a winging problem if noted in a OKC movement is to load that pattern and let the shoulder fix the abnormal pattern by itself. Sound a little like RNT? I think so true. (While I don’t demonstrate winging with a press but more with arm elevation, I’m sure you have seen clients that show instability with pressing. If there is no pain, the best way to fix the instability is by… thats right, pressing but with a load. Try it out
 
 
[wpvideo 67oDwjCO]
 
Not convinced that pressing heavy load will fix shoulder winging/ instability during flexion? Watch the next video and reassess your thought process. Hopefully I can convince you to give it a shot.
Kettlebell press with opposite arm-
 
 
[wpvideo XlREKayF]
So, What do you think?
 
3. Arm bar-
 
 
[wpvideo A0FdNoLp]
 
Watch those muscle trying hard to reflexively stabilize. Its oddly satisfying.
 
Time to wrap this up guys, but before I leave you here’s something to ponder about. For long we have thought of scapular instability to be closely related to sub acromial impingement. Not trying to be the devil’s advocate here but recent research has shown that scapular instability might not have a major role in impingement or pain in the shoulder (https://www.ncbi.nlm.nih.gov/m/pubmed/24174615/?i=2&from=/16015238/related). However, I take this with a grain of salt and always keep in mind that there are fallacies and shortcomings with research and this does not mean that it cannot be a cause of the above. Alas, such is research. I will still work on fixing this problem with my patients as I am looking for symmetry on both sides of the body not just for injury prevention but also for better performance.
Hope this blog helps.
 
Until next time-
Pursue excellence
Abhijit Minhas PT
(BPT, MS, CMP, FMT)
 
 
Reference-

1. Is there a relationship between subacromial impingement syndrome and scapular orientation? A systematic review. Ratcliffe E, et al. Br J Sports Med. 2014.