Frances: [00:00:00] So may as well get started. So just for anyone that doesn't know me, first of all, if you’re on my Instagram you might have a little bit of an idea. I'm Frances, I'm a physiotherapist I'm based in Brisbane. And I am chatting today with Louis, who is my, I would say my friend these days. Who's also a physio in Brisbane. So Louis graduated UQ from UQ as I did just a few years after I did, uh, he works at Excel physio in Hawthorne.

He's CrossFit level one coach. And he is like me particularly interested in evidence based practice. So I met Lewis, I guess it was last year. Yeah, through the gram reached yes, through the gram. So Louis reached out to me over Instagram and just kind of, you know, brought up that he felt like we had similar ideas and whether we wanted to meet and chat and Louis is actually one of the reasons I started doing my masters because Louis could quote Research off the top of his head and I'm like, I wanna be able to do that. So there we go. And what we're gonna talk about today is [00:01:00] scapula dyskinesis after Lewis telling me that he sort of was having a chat about it in his workplace the other day. So I wanted to ask you first can you even define, or can we define what scap DySIS is.

Louis: Yeah, thanks for having me on Francis it's, uh, I'm very, uh, honored to be the first guest for your, your live video series. So, so I mean, scapular dyskinesis it's I, I guess, uh, a bit of a longstanding theory in the, the shoulder pain and, and rehab world as to being a, a source of shoulder symptoms. So it's sort of defined as like a change or deviation from the normal resting position or active position of the shoulder blade while moving.

Okay. Okay. And, and it's, this is proposed that it may be a source of shoulder pain by increasing load on the rotator cuff and the contents of the subacromial space, uh, while you move. And then, I mean, in, from a mechanistic perspective, it makes good sense, right? Like it's, it's very intuitive. Yeah. It's [00:02:00] certainly a big issue for people who have dramas with like a, a neurological injury to their long thoracic nerve or accessory nerve.

So that will cause some really funky movement of the shoulder blade off the chest wall. But it's also proposed to potentially be something that causes pain in just regular run of the mill rotator cuff, shoulder pain. Yeah, I. There's a number of issues with this though, despite the fact that it sort of makes good sense on a, a theoretical level.

Yeah. Um, and, and it's like many things in musculoskeletal medicine, I think like we have these ideas that have really theoretical and then we take them and run with it. But then when we actually do some research into it, it, it proves that it's not really correct or doesn't really bear out. Like we thought it would.

Yeah. So if, if, if we think about the anatomy of the shoulder, right, you've got your. Your scapula suspended in the thorax by 17 different muscles, anchoring it to your mid back neck ribs and arm bone. Yeah. Um, so I mean, that's, there's quite a lot of moving parts there. [00:03:00] Yeah. And I, I think to define abnormal, we first have to be able to say what is normal.

Yeah. And when you dive into the literature on that, it's, it's very difficult to say what is a normal resting position at the scap what's normal in terms of, of the movement. Yeah. We've seen that the resting position tends to vary based on your hand dominance. So whether you're left or right handed the shoulder blade may sit slightly differently.

Um, what kind of upper limb activity you do regularly and habitual positions you put the shoulder in. So baseball pictures as an examples, the scaffold and the dominant side has been shown to rest slightly more upwardly, tilted, and internally rotated, and also tilted forward a little bit more than their UN that's actually their opposite side.

Frances: That's interesting. My dominant hand, like for sure does that. And I definitely attributed my shoulder pain a few years ago to that, and kind of went down the whole, like trying to assess my own scapula movement thing. So that's an interesting point.

Louis: it is interesting. Yeah. AB [00:04:00] absolutely. Um, I think the other thing too, like we, we have this idea that there's like, I guess that general pattern of scap movement where we like raise our arm overhead and that's to, to progressively upwardly, rotate to posteriorly tilt or tilt backwards and either turn in or out a little bit. Yeah. Um, there's also this notion of scapular humoral rhythm, which is that for every two degrees of movement at the ball and socket, you'll have one degree of the shoulder blade turning up, cuz the socket is part of the shoulder blade needs to face upward to help get our arm up, up to him. so does, that makes sense. Uni,

Frances: like I never thought about it ever again since uni, but I can remember those lectures very well.

Louis: That's a good thing that you haven't thought about too much. Cause it's actually not really true. Like we can probably see that the rate actually varies anywhere between like six to one and two to one.

Frances: Okay. Yeah.

Louis: The rhythm and how much movement there is. There is again with hand dominance with how fast you move, how tired you are. [00:05:00] If you're in pain and if you compare like a constrained task, like lifting your arm to a more functional activity, like throwing a ball or doing a snatch, you'll also see differences in how the same person shoulder blade moves.

So, I mean, if you think about like having a physio look at somehow someone's shoulder blade moves when they lift their arm or just how it sits at rest. um, that may not be overly relevant for somebody who's pain, uh, occurs while they throw a ball or why they, while they press a dumbbell overhead. So I, I think it, it's very challenging to actually say what is normal scapular movement. And, and as we'll go over sort of soon, there's, there's a lot of like I guess, asymmetry and differences in how it sits and how it moves even in people with, without shoulder pain. . Um, okay. So I guess you've basically defined it as well.

Frances: Dyskinesis is abnormal movement of the scapula. That's how it's defined. And that's what I learned at uni. But I guess our question [00:06:00] today is whether, is that a real thing and you're sort of indicating not necessarily. And I guess that leads me to my next question, which is, can we accurately assess, I suppose, scapular dyskinesia or scapular movement? And I ask that because I know that in. Athlete screening tools and stuff. They might have it in there. I'm trying to remember if in my subjects at uni last year, if we talked about it, probably it's one of those things that's always just thrown in as like a, you know, a throwaway line, like, is there abnormal movement of the scapula? So yes. Do you think we can accurately assess it in any way? And should like, should we bother and should we put it in screening tests for athletes?

Louis: I think it's worth looking at, like, I think we should always observe how it moves. I, I think that visual assessment of just subtle differences in scapular movement has very poor reliability. So what that means is if you and I both assess the same person's shoulder and watch how the shoulder [00:07:00] vapors moving, we probably have very different ideas about. How well is moving or how much upwards rotation there is or whatever. So it's, it's certainly yeah, the visual assessment, scap movement has poor into rider reliability, but I guess the exception would. When you have cases of like long thoracic nerve palsy or neurological injury it's very obvious that something very funky is going on. So it's, it's always worth looking at, but I guess, I don't think we can make a really good in clinic assessment, just relying on our eyes alone.

Frances: Can I just throw something in? I noticed too with me that like once, you know, what's side, It's like your ability to assess it accurately is gone because you know, it's hurting. So you are looking for those changes and, well, this is me anyway, but I'm sure other physios do it. Then you're kind of looking for something to blame. And so your ability to assess it, even yourself, I feel like it becomes quite hard once you know that what side is in pain, let alone someone else coming in and you. [00:08:00] Anyway. Yes. Go on.

Louis: Absolutely. And, and, and I think that's, that's interesting because we've got another paper that was done relatively recently. And, and what they did was they took a group of, of patients who either did or didn't have shoulder pain. And they had a group of therapists assess how their shoulder blades moved. And the experiment was, let's actually not tell one group of people who hasn't their shoulder pain and tell the others who does. And, and what they found was that therapists were more likely. Label someone with dyskinesis, if they knew they had shoulder pain beforehand. Yeah. Whereas the same. Yeah. Whereas the same people, the same people assess why a therapist who didn't know that they had shoulder pain, they were less likely to pick up anything function going on. So I guess it suggests that the way we're trained through uni and maybe through. these courses that some people go on, like tend to biases towards finding this, this dysfunction, even when it doesn't exist. It's, it's kind of like, pareidolia like, for instance, you see Jesus in this piece of toast. Oh.

And now, and now all you can [00:09:00] see is, is Jesus in the, in the piece of toast. So I think sometimes we, we see what we want to see or what we think should be there versus what really is. So I think that that's certainly a visual assessment. I don't know that there's a lot of good value in doing that outside of the gross neurological problems. yeah, scap movement can be more accurately assessed in a oratory setting where you have like 3d data from magnetic tracking systems and fancy stuff. But general day to day clinicians and coaches, you, you don't have a lot of chance unless something really funky is going on.

Frances: Yeah. Okay. So you're basically saying that for like in athlete, screening scenarios, where they do have access to that stuff, would you, do you think it's worthwhile? I think you might have said last time we chatted that there was maybe some evidence that in like a. Sport there was potentially some relevance.

Louis: Yeah. Yes. So they've done some prospective research on overhead athletes. So, you know, following a group of people over time from baseline looking at yeah. Who [00:10:00] had like nobody having shoulder pain to begin with and assessing scap dyskinesia, and then following them over a period of time. And they've done this in baseball, tennis. Badminton volleyball, um, handle. Yeah. So for the first four baseball, tennis, badminton, and volleyball, there was actually no association between having a funky scap at baseline and developing shoulder pain in the future.

Frances: do you know, and I'm really sorry to just ask you this, just in case you don't know the answer, but do you know how, how they assess it? Like, was it at rest? Was it with move? Do you know?

Louis: the, the two methods I've seen when I've read through the paper is either like this lab measure using that magnetic sort of technology to, to look at that. Oh, um, I've also seen it assessed using, um, Not so much with movement, but certainly resting position. They use like a tape measure to look at where the angle sits relative to the thoracic spine. And I think you've, you've probably seen this. And maybe when you raise your arm, then how far does it sit away again? But I think the better [00:11:00] papers tend to use the pretty flash 3d modeling to do it.

Frances: And do you think it's mainly, are they mainly looking at like lack of upper rotation or are they looking at it like, what's it called? "Winging" when it like sits.

Louis: Yeah, both, both they look at, they look at, does it, does it sort of internally rotate in the shoulder ways to lift off the chest wall? Does it properly rotate as much as the other side? Um, yeah. How much does it maybe tilt more forward or backwards? So, and they kind of all of the things, but yeah, all, they they'll look at everything, right. They tend to, because it has so many like degrees of freedom and obviously that much, that many muscles anchoring it to the chest wall. It's um, it's got, it's got a lot of potential movement available. . Yeah. So, um, so where there is some conflicting evidence is in high level handle. Okay. So we had, we had one study showing a small correlation, but another one sort of as like a replication study where there was no link.

Frances: Right.

Louis: So, I mean, potentially at the upper level of human shoulder function and maybe an argument that something being a little bit [00:12:00] off could be a risk factor. Yeah. But, um, it's, it's still a little bit ambiguous and I wouldn't say worth investing significant time or resources. We can actually prove that it is a problem for those people.

Frances: Yeah. Okay. And yeah, so that kind of covers whether we should screen for it in athletes, which to be honest is not the area I work in. So moving on to the area, that's more familiar to me. So considering someone who is already in pain do you think it is relevant how their scapula is moving?

Louis: I, I think it's, it's certainly worth looking at and I guess asking them about right. But I, I, I think again, the evidence doesn't really support that notion either. And it, it sort of speaks to a lot of these things that we've kind of deemed to. Dysfunctions in the body. I guess that are based on theory. Yeah, it's, it works in theory, but not really in, in practice as such. So there was a systematic review in 2013 that actually concluded that no physical examination test of the scapula was found to be useful [00:13:00] in differential diagnosing pathologies of the shoulder.

So it, can't actually like looking at those things in a clinic, can't really give you information about what's really going on with the, with the shoulder itself. And then the other thing that they said, and I'll have to quote this word for work, cause it's a great, great sentence. Scapular asymetry emotional position is not an indicator of shoulder dysfunction and is not limited to those with shoulder pathology. So, yeah, that kind of reiterates the point that some variation in asymmetry and how it sits and moves is actually really normal. Like it's not just isolated to people with shoulder pain. Yeah. I think where it may be relevant. And particularly when, like, it's not like a gross dyskinesis, but maybe it just feels funny to the person. Or maybe it looks a little bit funny to you. Like, I it's very hard to say, well, was that the cause? Or is this just something that's developed after they got sore?

Frances: Yeah.

Louis: So kind of like if you roll your ankle, you'll limp on it. Yeah. To take the pressure off. I think that it's reasonable to say that the muscles, the shoulder are gonna start to behave a bit differently when you're already sore. So it's kind of like a [00:14:00] limp. Yeah. So nobody, nobody looks at someone who's sprained their ankle and say, well, maybe if you weren't limping, you wouldn't have sprained it.

Frances: Yeah.

Louis: Like that's just, that's just bad reasoning. So, and, and I think it's kinda similar.

Frances: Yeah. I love, I love that idea because I feel like that's how I've started to really think about so many things. I see. The person comes in in pain. Cause that's what we usually see as physios. And then they're moving in this slightly abnormal way on that side. And then yes, we blame that and go, oh, that must be why, but exactly what you're saying. It could be that they're moving like that because of the pain. And so if you try and address that, it's probably not gonna get you anyway. So yeah, I love that thought and that, to me, out of like everything to do with dyskinesis is that's probably what speaks to me the most. In that, how can I trust what I'm assessing was there before? Um, and yeah, just something, I guess I noticed too, is that when someone's in pain and I'm, I know I do this, they're looking for something different to the other side and [00:15:00] attributing value, but they might have had that scap pattern forever. And then now that it's saw, you know, they're blaming that, but they also suddenly added lots of load and then, but they're blaming the abnormal movement.

Louis: Yeah. Absolutely. It's it's that, it's that whole thing around, like when we're sore, we, we go looking for answers, we go and try and find meaning and we be, we can sometimes become a bit hypervigilant. We sort of overanalyze what's what's going on here. Like, what is, what is the issue? Um, and we can pick up on some stuff that may have been there all along, but now that we're sore where we're sort of connecting the dots and they may be completely unrelated.

Frances: So my understanding is that there is some research that shows. That scap stability exercises do actually improve outcomes for people with shoulder pain. And just to clarify, like, what do you think a scap stability exercise would be? Like, I remember at uni, it was those weird lie on your stomach and do like lower traps. [00:16:00] And then I feel like, do you think those it, Y exercises, are they kind of scalability or what do you think?

Louis: Yeah, I think it depends on who you ask honestly. Right. But the idea is. If the scapular has to form a stable base for the glenohumeral joint to function on. Yeah. So if it, if it's not, if it's not set enough or not sort of absorbing enough force, then there's more load on the rotator cuff. But like I said before, the scap or the joint between the scapular and the rib cage is it's, it's quite a unique joint. And the only boney attachment between the shoulder blade and the body is by the collar. yeah. And the rest of it is just supported in, in muscle. It's like, like Jared Powell says it's suspended in a sling of muscle.

Right? So it's, it's not a very stable arrangement, right. It's just sort of on your chest wall anchored by muscle. So to call it stable. And if you look at how it moves, when we go there and it has to move around and turn up and down, it's not set in place. So no, I. When we talk about scapular [00:17:00] stability exercises, often we are talking about contracting those muscles or setting it in a certain position to try and take stress off part of the shoulder.

And, and I think these types of exercises have been proven to work for pain, but interestingly, that has nothing to do with changing the position of the scapula. Yes. So we, we've got a couple of RCTs. Now that show that you give the person a program and you watch 'em over a period of like six to 12 weeks and people get better and sometimes significantly better, but their scapular motion and timing of how the muscles work doesn't change.

Frances: yeah.

Louis: Despite the fact that that's, what's been emphasized, it's just exactly the same as, or a baseline. Yeah. Probably one of my favorite ones was done by Philip STR and colleagues in 2012. And it's one of the best described RCTs I've ever read.

 Philip and these guys, they, they really went into a lot of detail about each innovation and they talk, they talk you through every step and like every progression and regression and how they told people to avoid pain and all [00:18:00] these things. Right. And so they had they two groups with shoulder pain and a possible dyskinesia, and one was assigned exercises with like a heavy emphasis on where the scapula sits and working those muscles. And the other one was given more general exercises for the rotator cuff and a friction massage.

Frances: Okay.

Louis: In this study they found that the scapular exercises seemed to help more than pain with pain, I should say than the other one. However, it did not change the rest of the position of the scapula, right. Or how the scapula moved.

Frances: And I'm like curious. Now did the rotator cuff exercise group have a lower total dose of exercise?

Louis: Yeah. I was about to comment on that. It seems though they didn't do quite as much work, which does make things that, that again is a variable that maybe control well, um, yeah. . I mean, it, it, it kind of shows that this stuff can work, right. It's not that we have to throw the baby out the bath water. We can do exercises targeting the shoulder and the, so the [00:19:00] scapular muscles, I should say, but we don't have to go with the narrative of we're correcting your position because we're not. Yeah. Like that's just not, that's not true. Yeah.

Frances: And I guess it's like, that's the whole can of worms with exercise as a whole, in that even saying, like, I know there's been lots of discussions about do, is, does it actually make you stronger? And these types of. And it's like those narratives, like we're correcting movement or we're making you stronger, which sounds so obvious. It's actually not happening. So exercise, but exercise still works. And like, I love, I love that idea. Like I feel it's given me so much more freedom with how I prescribe stuff.

Cause I'm like, ah, it's, it's doing, I it's not correct. It might be correcting, but it's loading the part that hurts or it's getting you doing something that you thought you couldn't do before or building capacity. Like, whatever it. Yeah, so, but those things of it's "fixing your position". And the reason I asked about the workload was just because it reminded me of, I did it's slightly different.

It was rotator cuff tendinopathy, but there was a systematic review, I think last year. Cause I [00:20:00] did it for one of my assignments that was trying to look at whether like dose was relevant. Rotator cuff tendonopathy, which is like in the ballpark of what we're talking about. And it kind of, it was quite, there wasn't that many studies, but the thought was that whether it was higher load is in like weight or higher volume, it didn't really matter.

As long as you were doing more like the higher, the work load, the better the effects, which I thought was really interesting too, which is that idea of find something they can do and do heaps, just like make them do it often. And so I like that. And it's probably scandalous stability exercises are quite low, not very provocative of pain.

I reckon people in pain. So there might be a good choice, but the way we phrase it might be different.

Louis: Yeah, definitely. And it's not that they're bad options, right? It can, it can work for people. It's just not working for the reasons that we used to think it worked. Yeah. And that's, that's fine. But I think we probably need to shift the emphasis. Just doing stuff that people can tolerate that builds their ability to do stuff they wanna do [00:21:00] versus correcting dysfunctions.

Definitely. So I just have one more question, which is, if someone does come in with shoulder pain and their shoulder blade is moving abnormally and like say they, you know, they might notice cuz now that there's YouTube and Instagram, people are more clocked onto.

Frances: What might be going wrong and they might say, oh my scapular, move's funny. I have winging, I have scapular winging. Like I've been trying to fix it. And it's, you know what would you do? Just a general.

Louis: . That's I could go on for a while about that, but I think I'll try and keep it fairly brief, but I, I think probably the more common scenario is that, like, there might be some very. Asymmetry of scapular movement that I think is probably just normal and normal variation, but often people, or some people can feel like something really funky is going on there.

They're like, I feel like it's not seen right. It feels like something's wrong, it's moving wrong. And, and I think that like altered sensation of scapular movement, [00:22:00] Maybe like just a bit of a compensation to something going on with the rotator cuff. And that's actually supported by some of the research.

I know there was one RCT that looked at like how the shoulder blades move and when people do and don't have shoulder pain and in that study, they actually saw that people with shoulder pain actually rotated their shoulder blades upward more than the people. which is interesting, right? Cause that's, yeah, that's almost countered to what people think they think.

Well, no, it's not moving up enough that in this group is like they would, they were doing it more interesting. And, and perhaps that's that limp we're talking about. Right. There's just that slight change in how stuff's working, because they're important to get your arm up overhead. Your cuff is overloaded.

It's cranky. It's not really doing it's job very well. And now. Changes the behavior and how it feels.

Frances: That makes sense, like a hitch, like the thing where we do that.

Louis: Yeah, totally, totally. So I, I think that, like, I tend to, maybe I I'll obviously not dismiss the thought out of, out of [00:23:00] hand or I'll have a good look at it and I guess validate the way they're feeling, but also explain that look, there's nothing too funky going on, perhaps cause the cuffs a bit overworked, a bit grumpy that these muscles are having to work much harder to get the up over.

Okay. And, and maybe by getting rotator cuff doing a bit more and desensitizing it through rehab, we can actually get those muscles working a bit more like they normally would, or take a little bit of a load off and shifted elsewhere. Yeah. And then I I'll, I'll always look at like, yeah, assessing a person's rotator cuff strength or tolerance to, to pushing hard or like endurance and those things and trying to give somebody something to focus on that I, I tend to go with.

That Joe Gibson approach to that, to be honest, which she talks about the, the scapular muscles and the, she talks about the scapular muscles and the rotator cuff muscles are like G and T. Okay. They should never be, they should never be separated.

Frances: Yeah, I totally.

Louis: So, yeah. So I think I will, I will focus on a bit of that, but I'm certainly not necessarily telling people that I, yeah, your, your shoulder blade's gonna fall off your chest wall or anything that that's, [00:24:00] that's not really supported.

Frances: Yeah. And I guess The idea that they don't work separately is obviously really logical as well. Because as soon as you lift your arm, they're both gonna work. Like you can't isolate them. It's impossible. No. So definitely strengthening one. You're probably drinking other and yeah, I was just gonna say that.

The time when I saw the most kind of extreme example of scapula dyskinesis was when I was working in the UK. I've talked about this before. People had these really hyper, like very unstable shoulders as in truly unstable sort of slipping out of the socket, just with little movement kind of level, and their scapulas would do this huge... You could see the inferior angle, like winging big time off at the back. And you could just tell intuitively , that's not the issue here. And Anju Jaggi, who is this awesome physio I worked with over there explained it really well, which was that like, if your shoulder is gonna sleep off the socket, your body is gonna do whatever it can [00:25:00] to keep it on.

And so your scapula is gonna get under there and try to get under that, that bone and try to hold it in place. And so she kind of agreed that like the muscles that hold the rotator cuff, the muscles that hold the bone onto the socket is your rotator cuff muscle. so you really need to strengthen those to hold it in place.

And then the scapular muscles are kind of secondary. So it's probably going with what you're saying that rotator cuff is where it's at. And I suppose, I mean, rotator cuff exercises, again, like every exercise is rotator cuff exercise. So the world is our oyster really!

Louis: Yeah, totally. There's lots of options. Hey, it's just about finding what's gonna work best and what a person responds best to, and that can be a bit of a process to trial and. .

Frances: Yes. Okay. Well, I feel like we've covered everything I wanted to say. Unless there's anything else you would like to add?

Louis: No, that's great.

Frances:  So this was the best ever. Thank you so much. And I'm hoping that anyone watching next time you see one of those "fix your..." And then it's like scapular winging or something. Just [00:26:00] remember this conversation and that it probably doesn't really matter and just gets strong and that's it.

Louis: Cool.

Frances: All right. That's great. Thanks. Well, I'll see you soon and I will see everyone else doing another Instagram live in a few weeks.

Louis: Sounds great. Thanks Frances. Okay, bye.