Position and symmetry of scapulae:

Determine the position of the scapulae at rest and whether the two sides are symmetrical, although minor asymmetry is normal.

The normal scapula lies close to the rib cage with the vertebral border nearly parallel to and from 1 to 3 inches lateral to the spinous processes. The inferior angle is on the chest wall. The most prominent abnormal posture of the scapula is “winging,” in which the vertebral border tilts away from the rib cage, a sign indicative of serratus anterior weakness (Figure 5-5). Other abnormal postures are abduction and downward rotation of the scapula. If the inferior angle of the scapula is tilted away from the rib cage, check for tightness of the pectoralis minor, weakness of the trapezius, and spinal deformity.

Scapulohumeral rhythm improves the shoulder’s range of motion and consists of integrated movements of the glenohumeral, scapulothoracic, acromioclavicular, and sternoclavicular joints. It occurs in sequential fashion to allow full functional motion of the shoulder complex. To complete 180° of shoulder abduction, the overall ratio of glenohumeral to scapulothoracic motion is 2 : 1.

Scapular range of motion:

Within the total arc of 180° of shoulder forward flexion and abduction are 120° of glenohumeral abduction and 60° of scapular rotation. Glenohumeral and scapular movements occur not as separate motions, but as synchronous motions throughout the range.

a. The scapula sits against the thorax (T) during the first phase of shoulder abduction and flexion to provide initial stability as the humerus (H) abducts and flexes to 30°.

b. From 30° to 90° of flexion and abduction, the glenohumeral (G-H) joint contributes another 30° of motion, whereas the scapula upwardly rotates 30°. The upward rotation is accompanied by clavicular elevation through the sternoclavicular and acromioclavicular joints (Figure 5-6, A).

c. The second phase (90° to 180°) is made up of 60° of glenohumeral abduction and flexion and an additional 30° of scapular upward rotation. The scapular rotation is associated with 5° of elevation at the sternoclavicular joint and 25° of rotation at the acromioclavicular joint (Figure 5-6, B).

Passively raise the test arm completely above the head in forward flexion to determine scapular mobility. The scapula should start to rotate at about 30°, although there is considerable individual variation. Scapular rotation continues until about −20° to −30° from full flexion.

Check that the scapula basically remains in its rest position at ranges of shoulder flexion less than 30° of forward flexion (the position is variable among subjects). If the scapula moves a lot as the glenohumeral joint moves through from 0 to 60°—that is, if in this range they move as a unit—there is limited glenohumeral motion. Above 30° and to about 150° or 160° in both active and passive motion, the scapula moves in concert with the humerus.

The serratus should always be tested in shoulder flexion to minimize the synergy with the trapezius.

If the scapular position at rest is normal, ask the patient to raise the test arm above the head in the sagittal plane. If the arm can be raised well above 90° (glenohumeral muscles must be at least Grade 3 to do this), observe the direction and amount of scapular motion that occur. Normally, the scapula rotates forward in a motion that is controlled by the serratus, and if erratic or “uncoordinated” motion occurs, the serratus is most likely weak. The normal amount of motion of the vertebral border from the start position is about the breadth of two fingers (Figure 5-7). If the patient is able to raise the arm with simultaneous rhythmical scapular upward rotation, proceed with the test sequence for Grades 5 and 4.

Scapula abnormal position at rest:

If the scapula is positioned abnormally at rest (i.e., downwardly rotated, abducted, or winging), the patient will not be able to flex the arm above 90°. Proceed to tests described for Grades 2, 1, and 0.

The serratus anterior never can be graded higher than the grade given to shoulder flexion. If the patient has a weak deltoid, the lever for testing is gone, and the arm cannot be used to apply resistance.

Position of Patient (All Grades):

Short sitting over end or side of table. Hands on lap.

Position of Therapist:

Standing at test side of patient. Hand giving resistance is on the arm proximal to the elbow (Figure 5-8). The other hand uses the web space along with the thumb and index finger to palpate the edges of the scapula at the inferior angle and along the vertebral and axillary borders.

Test:

Patient raises arm to approximately 130° of flexion with the elbow extended. (Examiner is reminded that the arm can be elevated up to 60° without using the serratus.) The scapula should rotate (glenoid facing up) and abduct without winging.

Instructions to Patient:

“Raise your arm forward over your head. Keep your elbow straight; hold it! Don’t let me push your arm down.”

Positions of Patient and Therapist:

Same as for Grade 5 test.

Test:

Patient raises the arm to approximately 130° of flexion with the elbow extended (Figure 5-9).

Instructions to Patient:

“Raise your arm forward above your head.”

Position of Patient:

Short sitting with arm forward flexed to about 130° and then protracted in that plane as far as it can move.

Position of Therapist:

Standing at test side of patient. Hand used for resistance grasps the forearm just above the wrist and gives resistance in a downward and backward direction. The other hand stabilizes the trunk just below the scapula on the same side; this prevents trunk rotation.

The examiner should select a spot on the wall or ceiling that can serve as a target for the patient to reach toward in line with about 130° of flexion.

Test:

Patient abducts and upwardly rotates the scapula by protracting and elevating the arm to about 130° of flexion. The patient then holds against maximal resistance.

Instructions to Patient:

“Bring your arm up, and reach for the target on the wall.”

Position of Patient:

Short sitting with arm flexed above 90° and supported by examiner.

Position of Therapist:

Standing at test side of patient. One hand supports the patient’s arm at the elbow, maintaining it above the horizontal (Figure 5-10). The other hand is placed at the inferior angle of the scapula with the thumb positioned along the axillary border and the fingers along the vertebral border (see Figure 5-10).

Test:

Therapist monitors scapular motion by using a light grasp on the scapula at the inferior angle. Therapist must be sure not to restrict or resist motion. The scapula is observed to detect winging.

Instructions to Patient:

“Hold your arm in this position” (i.e., above 90°). “Let it relax. Now hold your arm up again. Let it relax.”

Position of Patient:

Short sitting with arm forward flexed to above 90° (supported by therapist).

Position of Therapist:

Standing in front of and slightly to one side of patient. Support the patient’s arm at the elbow, maintaining it above 90° (Figure 5-11). Use the other hand to palpate the serratus with the tips of the fingers just in front of the inferior angle along the axillary border (see Figure 5-11).

Test:

Patient attempts to hold the arm in the test position.

Instructions to Patient:

“Try to hold your arm in this position.”

Position of Patient:

Lying on table with arm forward flexed to 90° (supported by therapist).

Position of Therapist:

Standing to the same side as arm being tested. Support the patient’s arm at the elbow, maintaining the arm above 90° (Figure 5-12). Use the other hand to palpate the serratus with tips of fingers just in front of the inferior angle along the axillary border.

Test:

Patient attempts to hold the arm in the test position.

Instructions to Patient:

“Try to hold your arm in this position.”

Position of Patient:

Short sitting over end or side of table. Hands relaxed in lap.

Position of Therapist:

Standing behind patient. Hands contoured over top of both shoulders to give resistance in a downward direction. The therapist’s arms should be nearly straight, transferring the therapist’s body weight through the arms to provide enough resistance to this typically strong muscle.

Test:

It is important to examine the patient’s shoulders and scapula from a posterior view and to note any asymmetry of shoulder height, muscular bulk, or scapular winging. This kind of asymmetry is common and can be caused by carrying purses or briefcases habitually on one side (Figure 5-16).

Patient elevates (“shrugs”) shoulders. In the sitting position, the test is almost always performed on both sides simultaneously.

Instructions to Patient:

“Shrug your shoulders.” OR “Raise your shoulders toward your ears. Hold it. Don’t let me push them down.”

Position of Patient and Therapist:

Same as those used for Grade 5 test except that no resistance is given (Figure 5-18).

Test:

Patient elevates shoulders through range of motion.

Instructions to Patient:

“Raise your shoulders toward your ears.” OR “Shrug your shoulders.”

Position of Patient:

Prone or supine, fully supported on table. If prone, head is turned to one side for patient comfort (Figure 5-19). If supine, head is in neutral position.

Position of Therapist:

Standing at test side of patient. Support test shoulder in palm of one hand. The other hand palpates the upper trapezius near its insertion above the clavicle. A second site for palpation is the upper trapezius just adjacent to the cervical vertebrae.

Test:

With the therapist supporting the shoulder, the patient elevates the shoulder (usually done unilaterally) toward the ear.

Instructions to Patient:

“Raise your shoulder toward your ear.”

Position of Patient:

Prone with shoulder at edge of table. Shoulder is abducted to 90°. Elbow is flexed to a right angle (Figure 5-23). Head may be turned to either side for comfort.

Position of Therapist:

Standing at test side close to patient’s arm. Stabilize the contralateral scapular area to prevent trunk rotation. There are two ways to give resistance; one does not require as much strength as the other.

1. When the posterior deltoid is Grade 3 or better: The hand for resistance is placed over the distal end of the humerus, and resistance is directed downward toward the floor (see Figure 5-23). The wrist also may be used for a longer lever, but the lever selected should be maintained consistently throughout the test.

2. When the posterior deltoid is Grade 2 or less: Resistance is given in a downward direction (toward floor) with the hand contoured over the shoulder joint (Figure 5-24). This placement of resistance requires less adductor muscle strength by the patient than is needed in the test described in the preceding paragraph.

The fingers of the other hand can palpate the middle fibers of the trapezius at the spine of the scapula from the acromion to the vertebral column if necessary (Figure 5-25).

Test:

Patient horizontally abducts arm and adducts scapula.

Instructions to Patient:

“Lift your elbow toward the ceiling. Hold it. Don’t let me push it down.”

Position of Patient and Therapist:

Same as for normal test except that the therapist uses one hand to cradle the patient’s shoulder and arm, thus supporting the arm’s weight (Figure 5-26), and the other hand for palpation.

Test:

Same as that for Grades 5 to 3.

Instruction to Patient:

“Try to lift your elbow toward the ceiling.”

Position of Patient:

Prone. Place scapula in full adduction. Arm is in horizontal abduction (90°) with shoulder externally rotated and elbow fully extended.

Position of Therapist:

Standing near shoulder on test side. Stabilize the opposite scapular region to avoid trunk rotation. For Grades 5 and 4, give resistance toward the floor at the distal humerus or at the wrist, maintaining consistency of location of resistance.

Instructions to Patient:

“Keep your shoulder blade close to the spine. Don’t let me draw it away.”

Test:

Patient maintains scapular adduction.

Position of Patient:

Prone with test arm over head to about 145° of abduction (in line with the fibers of the lower trapezius). Forearm is in midposition with the thumb pointing toward the ceiling. Head may be turned to either side for comfort.

Position of Therapist:

Standing at test side. Hand giving resistance is contoured over the distal humerus just proximal to the elbow (Figure 5-30). Resistance will be given straight downward (toward the floor). For a less rigorous test, resistance may be given over the axillary border of the scapula.

Fingertips of the opposite hand palpate (for Grade 3) below the spine of the scapula and across to the thoracic vertebrae, following the muscle as it curves down to the lower thoracic vertebrae.

Test:

Patient raises arm from the table to at least ear level and holds it strongly against resistance. Alternatively, preposition the arm in elevation diagonally over the head and ask the patient to hold it strongly against resistance.

Instructions to Patient:

“Raise your arm from the table as high as possible. Hold it. Don’t let me push it down.”

Position of Patient:

Prone. Head may be turned to either side for comfort. Shoulder is internally rotated and the arm is adducted across the back with the elbow flexed and hand resting on the back (Figure 5-36).

Position of Therapist:

Standing at test side. When the shoulder extensor muscles are Grade 3 or higher, the hand used for resistance is placed on the humerus just above the elbow, and resistance is given in a downward and outward direction (Figure 5-37).

When the shoulder extensors are weak, place the hand for resistance along the axillary border of the scapula (Figure 5-38). Resistance is applied in a downward and outward direction.

The fingers of the hand used for palpation are placed deep under the vertebral border of the scapula.

Test:

Patient lifts the hand off the back, maintaining the arm position across the back at the same time the examiner is applying resistance above the elbow. With strong muscle activity, the therapist’s fingers will “pop” out from under the edge of the scapular vertebral border (see Figure 5-36.)

Instructions to Patient:

“Lift your hand. Hold it. Don’t let me push it down.”