A scapula retraction

It is becoming a trend of mine to do a post in the last few hours of the year. Please ignore that this is my first post for 2017!

I have had a run of shoulder patients over the last few months, a number of which have been having treatment with other providers, the vast majority of them “setting” their scapula in a retracted position (in layman’s terms “pulling the shoulder-blade back and down”) while doing their other exercises such as biceps curls, shoulder presses et cetera.

Like “core stability” this trend of scapula retraction seems to have also become entrenched in clinical practice. I should know, I used to give all of my neck, shoulder and thoracic pain patients scapula retraction exercises. In hindsight, without having a valid reason for doing it!

Some of the research I have become aware of over the past few years (obviously not an exhaustive list……):

• Just because a patient has differences in scapula symmetry side to side, we should not assume this is a “dysfunction” as pain-free individuals can demonstrate scapula asymmetry (Morais and Pascoal, 2013).
• Scapula dyskinesis is not necessarily more prevalent in those with shoulder pain (Plummer et al, 2017).
• When the patient exhibits symptoms we should be utilising “repositioning tests” to ascertain if the symptoms can be changed. If symptoms can be reduced, there is potentially merit in targeting this “dysfunction” as part of treatment. “Symptom modification” is a commonly used term to describe this. [Struyf et al (2014), Lewis et al (2016), and another Lewis et al (2016)].

But interestingly (again, not an exhaustive list):

• Scapula focused treatment/exercise approaches do not necessarily appear superior to generalised approaches (Bury et al, 2016).
• There is insufficient evidence to support or disprove specific exercise strategies for treatment of individuals with subacromial impingement syndrome (Shire et al, 2017).
• Studies like Hotta et al (2017) provide support for scapula focused exercise regimes, but this particular study compared the exercise group with another group…..that was not treated.
• Maybe we just ignore the scapula and get them “lifting” and “pushing” within sensible pain parameters based on what they have trouble doing. And maybe they just need 1 single exercise, rather than a complex exercise regime (Littlewood et al, 2016).

Clear as mud?

I could go on, but I doubt it would get any clearer! Like most things in clinical practice, there is plenty of uncertainty, and I think this is a good thing.

Time for some low-level evidence:

My thoughts:

• Assess the impact of altering scapula positioning on a patient’s symptoms, call it “symptom modification” if you like.
• Look for significant improvement in symptoms. In line with some of the references above this at least needs to be within the realms of a to 20 to 30% improvement. Anything less than this is arguably not very important (Ostelo et al 2008).
• Ideally we should utilise a painful functional task, but a painful/limited movement or test will suffice. You could even assess the impact on resting pain (assuming they have pain at rest).
• We may need to combine a number of different options/changes to scapula position and other areas (neck or thoracic spine for example) to see if we get a “cumulative” change.
• I do not think we need to stick to a set procedure with this sort of assessment. We also should not have to devote a significant amount of time to  it. I think realistically, once you get efficient at it, it should not take much longer than a minute or so. Having said that, there is nothing inherently wrong following a “routine”.
• Don’t get obsessed with being able to change pain. Sometimes you cannot, and there can be many reasons for this (that will need to be another post) but as an example think about someone with a highly “inflamed” or “sensitised” shoulder. Are we likely to be able to change their symptoms significantly?
• If you can obtain a meaningful change in symptoms then I think you can quite reasonable commence strategies/exercises to target this. Though I am not convinced this needs to be done in the long-term, probably just long enough until pain starts to settle significantly. Then we can probably forget about it. Though patients are individuals.
• If you cannot change the patients pain at all with alterations to scapula position, then I struggle to see why you would focus on it as part of the treatment. They might just need to do strengthening exercises without focussing on their scapula.
• I recognise that sometimes a patient’s scapula is perhaps not “moving” because it is “stiff”. This is reasonable, assuming that treating this improves the symptoms, in a meaningful way, in a reasonable period of time (it should not take months or even weeks to begin to see some chance). A within treatment change is reasonable to expect if the “stiffness” is a dominant issue and some sort of manual therapy or stretching is done to assist. See these references for information on this [Tuttle, (2009) and Trott et al  (2014)]. Exercises will also need to be included, we shouldn’t just do manual therapy……..
• I struggle to see why we would get a patient to repeatedly work on a certain “scapula position” if it repeatedly and consistently worsens their symptoms (I have seen this quite a bit). While some might argue that they are “desensitising” their pain (i.e. graded exposure), and I think this is reasonable in some cases, if you have been working on this for weeks or even months with no improvements then the argument significantly weakens. You might just be repeatedly and consistently aggravating their pain levels!
• I can see reason why you might not even assess scapula position given some of the research outlined above. My bias is that I do. Some key reasons being that:
  • I feel it can guide treatment.
  • Being able to show a patient they can reduce symptoms is to me a positive and sometimes very powerful thing.

My key point:

Don’t give scapula retraction exercises (or any exercise for that matter) just for the sake of doing so.

This doesn’t mean you can’t get them to do other exercises such as shoulder presses or biceps curls if this is relevant.

Just don’t give scapula retraction exercises (or any exercise for that matter) just for the sake of doing so.

Thanks for reading.

Happy New Year to you all. Best wishes for 2018!

Cheers

Mark