It is no secret that proper scapula alignment and muscle activation makes for a healthy shoulder.  There are many forms of dysfunction that may be present.
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Generally speaking problems revolve around muscular tightness/weakness and faulty movement patterns.  The term “SICK” scapula is often used and refers to Scapula Inferior Coracoid Dyskinesis.  Common examples of a “sick”  scapula include:
  • Type I - Inferior border prominence.  This is typically related to tightness in the pec minor and weakness in the lower trapezius.  Keep in mind the upper trapezius will naturally dominate the lower trap in the force couple with the serratus anterior for upward rotation.  You may also see increased thoracic kyphosis which will inhibit the normal resting position of the scapula.
  • Type II - Medial border prominence.  In this case the scapula is internally rotated or protracted and there is liekly weakness present in the rhomboids and middle trapezius.  The serratus anterior may also likely be weak with evidence of scapular winging.  This position places the humerus in relative internal rotation and increases risk of impingement with arm elevation.
  • Type III - Superior border presence.  Here the scapula appears elevated in the face of an overactive upper trap and/or levator scapulae.  With active arm elevation, you may notice excessive shrugging or superior humeral head migration in light of the imbalance.  Again, the lower trapezius is probably weak and being overpowered.
Click here for a great graphic display from the Journal of the American Academy of Orthopaedic Surgeons of how the scapular muscles work collectively as a force couple to promote optimal movement in the shoulder.
In many of the throwers and overhead athletes I see in the clinic, they often exhibit either medial border prominence of inferior border prominence.   Additionally, I frequently observe GIRD (glenohumeral internal rotation deficit) values of 20 degrees or higher in those patients who come in with symptomatic shoulders (rotator cuff and/or labral issues).  What does this mean?
Well, in a nutshell, it means addressing posterior capsule tightness in the throwing shoulder is important for avoiding internal impingement and SLAP tears.  Tightness (or too much GIRD) can increase the load/tension in the late cocking phase of throwing thereby contributing to friction between the cuff and labrum, as well as excessive torsion on the proximal biceps tendon.  Any excessive humeral head migration with repetitive throwing is a recipe for injury over time.
While some debate the merits of the sleeper stretch, current outcome data with respect to SLAP tears indicates that resolving GIRD and scapular dyskinesia is the best measure for success in dealing with labral injuries in throwers.  I have great success in resolving pain when utilizing posterior capsule stretching as part of my programs.  So, I routinely address GIRD by mobilizing the glenohumeral joint with posterior mobilizations if deemed necessary, as well as manual sleeper and cross body stretches.
Click here for a related post and video on posterior shoulder stretches that demonstrates these maneuvers.
If you discover pec minor tightness (and you will most ofthe time) then implement soem soft tissue mobilization (see pic below) followed by routine flexibility.  I prefer to use a trigger point ball and roll for 30-60 seconds.
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I use the following stretch after the soft tissue work to address pec minor tightness:
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After addressing soft tissue restrictions, attacking the scapular muscles is next!  It is a given to include scapular mainstays such as prone I, Y and T exercises, as well as prone row with external rotations (W’s) when the client is ready.  However, I really think the big bang for your buck will come in the form of closed chain scapular stability training that also calls for lots of core activation and loading through the glenohumeral joint.
Basic examples include quadruped rocking (progressing from two to one arm), scapular clock exercises (ball on wall moving to BOSU), chair press-ups, scapular y raises from a tall 4 point plank position and prone serratus push-ups.  As patients master stability with these exercises, I will move toward more unstable varieties.
Below is a short sample video I shot with one of my interns using some more advanced unstable closed kinetic chain stability exercises on the iJoy Board.  This is a fun little toy we use at our facility to enhance proprioception and stability.  I utilize these with my higher level clients to integrate shoulder, core and hip stability.