Movements of the Scapula
Evaluation and Measurements
I. Devreux
Testing and Measurements
Physical Therapy - Ms. I. Devreux
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Testing and Measurements
Physical Therapy - Ms. I. Devreux
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Anatomical Reminder
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Movements of the Scapula
1. Scapular Abduction & upward
rotation: Serratus Anterior.
2. Scapular Elevation: Trapezius upper
fibers & Levator Scapulae.
3. Scapular Adduction: Trapezius middle
fibers.
4. Scapular Depression & Adduction:
Trapezius lower fibers.
5. Scapular adduction & downwards
rotation: Rhomboids.
Testing and Measurements
Physical Therapy - Ms. I. Devreux
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SCAPULAR ABDUCTION AND
UPWARD ROTATION:
Serratus Anterior
Evaluation and Measurement
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Scapular Abduction and upward rotation:
Serratus anterior
 Origin: Outer surfaces & sup.
borders of upper 8 or 9 ribs.
 Insertion: Costal surface of medial
border of scapula.
Nerve: C5,C6,C7,C8
ROM: = to 3 to 4 fingers space.
 Limited by:
• Tension of trapezoid ligament
(forward rot. of scapula upon
clavicle).
• Tension of trapezius and
Testing and Measurements
rhomboid major and minor.
Physical Therapy - Ms. I. Devreux
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Ligaments
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Scapular Abduction and upward rotation:
Serratus anterior
Action:
 With the origin fixed it abducts
the scapula, rotates it so the
glenoid cavity faces cranially &
holds the medial border of the
scapula firmly against the
thorax.
 The lower fibers may depress
the scapula & the upper fibers
may elevate it slightly.
 With the humerus in flexion &
the hands against a wall, the
serratus acts to displace the
thorax posteriorly as the effort is
made to push the bodyTesting
away
and Measurements
from the wall.
Physical Therapy - Ms. I. Devreux
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Scapular Abduction and upward rotation:
Serratus anterior
Grade 3 testing procedure:
• Pt. is backlying with arms
flexed to 90° & scapula
resting on table.
• Therapist stands beside the
table at level of the hips.
Prox. hand is fixing the
thorax sideways just below
the scapula.
• Command: »Push your arm
in front of you as if you want
to reach the ceiling ---relax ».
Testing and Measurements
Physical Therapy - Ms. I. Devreux
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Scapular Abduction and upward rotation:
Serratus anterior
Grades 4 & 5 (Good & Normal)
• Pt. in backlying w/ arm flexed at
90°.
• Therapist is at the level of pt.
head. Proximal hand grasps
around the pt.’s elbow & distal
hand grasps around the pt.’s
wrist and forearm.
• Resistance: moderate ( gr. 4) &
maximal ( gr. 5) leading
resistance is given pressing
down directly opposite line of
raising + hold for gr. 5.
• « Push your arm in front of you
as if you reach the ceiling
(+andhold
Testing
Measurements
Physical Therapy - Ms. I. Devreux
for gr. Gr.5). »
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Scapular Abduction and upward rotation:
Serratus anterior
Note:
• Do not allow winging of the
scapula.
• Observe possible substitution
by the ant. ms. of the shoulder.
• To isolate more intensively, the
resist. of the prox. hand can be
used to apply res. on the lat.
border of the scapula.
• The ® will be given in the
direction of rotating the scapula
infer. angle medially.
• The distal hand will grasp the
arm just below the shoulder
joint.
• The pt. can be tested in sitting,
arm flexed at 120°.
Testing and Measurements
Physical Therapy - Ms. I. Devreux
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Scapular Abduction and upward rotation:
Serratus anterior
Grade 2 testing:
• Pt. in sitting with arm flexed
at 90° & arm resting on the
table.
• Therapist stands behind the
patient & stabilizes the
thorax with proximal hand
placed over the shoulder.
• Command: « Push your arm
forward sliding it on the table
--- Relax. »
Testing and Measurements
Physical Therapy - Ms. I. Devreux
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Scapular Abduction and upward rotation:
Serratus anterior
Grade 1 & 0 (Trace & Zero
grade):
• Pt. In sitting with arm flexed at
90° without the table support.
• Therapist stands facing the
affected shoulder.
Prox. hand is on the outer
surface of the ribs to palpate
contraction.
• Distal hand grasps the pt. arm
forcing it slightly backwards to
stimulate contraction. Testing and Measurements
Physical Therapy - Ms. I. Devreux
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Scapular Abduction and upward rotation:
Serratus anterior
Effect of weakness:
• Main sign: winging of the
scapula.
Sign of paralysis:
• Unability to raise the arm
overhead.
Testing and Measurements
Physical Therapy - Ms. I. Devreux
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Another movement
• Scapular Elevation
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SCAPULAR ELEVATION
Muscles:
Trapezius ( upper fibers)
Levator Scapulae
1) Trapezius:
Origin:
• External occipital protuberance
• Medial 1/3 of superior nuchial
line.
• Spinous process of C7.
Insertion:
• Lateral 1/3 of clavicle
• Acromion process of scapula.
Nerve: C2, C3, C4.
Testing and Measurements
Physical Therapy - Ms. I. Devreux
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SCAPULAR ELEVATION
Muscles:
Trapezius ( upper fibers)
Action:
• Upper fibers of trapezius
elevate the scapula.
• With the insertion fixed
and acting unilaterally, the
upper fibers extend laterally,
flex and rotate the head and
joints of the cervical
vertebrae so that the face
turn toward the opposite
side.
• With the insertions fixed
and acting bilaterally the
upper trapezius extends the
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head and neck.
Physical Therapy - Ms. I. Devreux
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SCAPULAR ELEVATION
Muscles:
Levator Scapulae
Origin: Transverse processes of the
first 4 cervical vertebrae.
• Insertion: Medial border of
scapula between sup. angle and
root of the spine.
• Nerve: dorsal scapular nerve: C3
C4 C5
Action: With origin fixed: elevates
the scapula & assists in rotation
→glenoid cavity faces caudally.
• With insertion fixed & acting
unilaterally, it rotates & flexes the
cerv. vertebrae to the same side.
• Acting bilaterally: assists
in ext.
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of cerv. Spine.
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Scapular Elevation
• Examine the patients
shoulders and scapula from a
posterior view & to note :
– any assymmetry of shoulder
height,
– muscular bulk,
– or scapular winging.
• This kind of assymmetry is
common & can be caused by
carrying purses or briefcases
habitually on one side.
• The test will be performed on
both sides simultaneously.
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Physical Therapy - Ms. I. Devreux
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SCAPULAR ELEVATION
Muscles:
Trapezius ( upper fibers)
Levator Scapulae
Accessory muscles: Rhomboid
major and minor.
ROM: With full ROM, the
shoulder is brought up with
a distance of 3 fingers
separating it with the inf.
lobe of the ear.
Limited ROM:
• Tension of costoclavicular
ligament.
• Tension of muscles
depressing the scapula and
clavicle: pectoralis minor,
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subclavius, trapezius (lower
Physical Therapy - Ms. I. Devreux
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SCAPULAR ELEVATION
Muscles:
Trapezius ( upper fibers)
Levator Scapulae
Grade 3 testing procedure:
• Pt. is sitting with arms at
sides.
• Therapist stands behind the
pt.
• Command: « pull your
shoulders upward as much
as you can---relax ».
Testing and Measurements
Physical Therapy - Ms. I. Devreux
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SCAPULAR ELEVATION
Muscles:
Trapezius ( upper fibers)
Levator Scapulae
Grades 4 & 5:
• Pt. is sitting with arms at sides.
• Therapist is behind the pt. &
places his 2 hands over each
shoulder for resistance.
• Gr. 4: Moderate resistance by
pressing down;
• Gr. 5 max. resistance down +
hold at end of ROM.
• Command: « Pull your
Testing and Measurements
shoulders up---( hold)---relax.
Physical Therapy - Ms. I. Devreux
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SCAPULAR ELEVATION
Muscles:
Trapezius ( upper fibers)
Levator Scapulae
Grade 2: Poor strength:
• Pt. is in prone lying.
• Therapist stands at the level
of the waist.
• His 2 hands grasp each
shoulder to support them.
• Command: « Pull your
shoulders towards your ears--relax ».
Grade 1& 0: palpate upper
fibers of trapezius, parallel to
cervical vertebrae & near the
insertion above clavicle.
Testing and Measurements
Physical Therapy - Ms. I. Devreux
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ANOTHER MOVEMENT
• Scapular
Adduction:
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Scapular Adduction
Trapezius (Middle fibers):
• Origin: spinous processes
of 1st – 5th thoracic
vertebrae.
• Insertion: sup. lip of spine
of scapula.
• Nerve: C2, C3, C4.
• Action: scapular adduction.
• Stabilization role during
scapula downwards
rotation.
Testing and Measurements
Physical Therapy - Ms. I. Devreux
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Scapular Adduction
Accessory muscles:
• Trapezius upper & lower
fibers.
• Rhomboid major & minor.
ROM: From ABD. position to
the add. position: 3 to 4
fingers.
Limited ROM: Tension of
coronoid ligament( limits
backward rot. of scapula
upon clavicle).
• Tension of pectoralis major
& minor & serratus ant. ms.
• Contact of the vertebral
border of scapula with Testing and Measurements
spinal musculature Physical Therapy - Ms. I. Devreux
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Scapular Adduction
Grade 3 testing procedure:
• Pt. is in prone lying with arm
abducted to 90°, lat. rotated, &
elbow flexed to a right angle.
• Therapist stands at level of
waist, proximal hand is over
thorax below the scapula to
stabilize thorax.
• Command: « raise your arm up
( in horiz. abd) & adduct the
scapula ---relax. »
Testing and Measurements
Physical Therapy - Ms. I. Devreux
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Scapular Adduction
Grades 4 & 5: normal & good.
• Patient in prone, with arm at
90° abd. & elbow flexion.
• Therapist: proximal hand
stabilizes thorax, distal hand
applies resistance on the
lateral angle of the scapula
(no pressure on humerus).
• Resistance: moderate ( gr. 4)
or max. opposite movement
+ hold for gr. 5.
• Command: « raise your arm
up + adduct the scapula +
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hold if gr. 5. »
Physical Therapy - Ms. I. Devreux
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Scapular Adduction
Note : The motion here
must take place at the
scapula & not in the
gleno-humeral joint.
To ensure the isolation of
the scapula, the grades 3,
4 & 5 may be tested with
the arm in adduction &
elbow flexion. It can also
be in sitting position.
• Substitution: the
Rhomboids can
substitute for the
trapezius in adduction of
the scapula.
• However they can not
substitute in the upward
rotation component.
• When the Rhomboid
substitute: scapula will
adduct + rotate
downward.
Testing and Measurements
Physical Therapy - Ms. I. Devreux
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Testing and Measurements
Physical Therapy - Ms. I. Devreux
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Scapular Adduction
Grade 2 : Poor strength.
• Pt. is in sitting with affected
arm resting on a table in a
position midway between
horizontal add. & abd.
• Therapist in front of pt. with 1
hand placed over the
opposite shoulder to stabilize
thorax.
• Command: « Pull your arm
backwards & bring your
scapula back & in ---relax. »
Testing and Measurements
Physical Therapy - Ms. I. Devreux
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Scapular Adduction
Grade 1 & 0 : Trace and Zero:
• Pt. is in sitting with affected arm
resting on a table in a position
midway between horizontal add.
& abd.
• Therapist stands beside the
opposite shoulder.
Distal hand is placed over the
opposite shoulder to stabilize
thorax.
Prox. hand palpates contraction
between the roots of the spine of
scapula & vertebral column.
• Command: « Try to pull your arm
slightly backward & bring your
scapula in ---relax »
Testing and Measurements
Physical Therapy - Ms. I. Devreux
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ANOTHER MOVEMENT
Scapular Depression and Adduction: Trapezius
( lower fibers)
Testing and Measurements
Physical Therapy - Ms. I. Devreux
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Scapular Depression and
Adduction: Trapezius ( lower fibers)
Origin: Spinous processes of
6th – 12th thoracic vertebrae.
Insertion: Apex of spine of
scapula.
Nerve supply: C2, C3, C4.
Action: Mainly depresses the
scapula.
Stabilizes when the upper &
middle fibers are working.
Accessory: Trapezius middle
fibers.
Testing and Measurements
Physical Therapy - Ms. I. Devreux
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Scapular Depression and
Adduction: Trapezius ( lower fibers)
ROM: 5 to 4 fingers.
• Motion is similar to
adduction.
ROM is limited by:
• Tension of interclavicular
ligament & articular disc of
sternoclavicular joint.
• Tension of trapezius ( upper
fibers), levator scapulae &
sternocloido-mastoideus (
clavicular head) ms.
Testing and Measurements
Physical Therapy - Ms. I. Devreux
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Scapular Depression and Adduction:
Trapezius ( lower fibers)
Testing of grade 3 - 2: Fair &
Poor strength
• Pt. is in prone lying with
forehead on table & arm to
be tested extended
overhead.
• Therapist faces the patient’s
head. One hand is used to
support the arm if deltoid
muscle is weak.
• Command: « Pull your arm
slightly up & pull your
scapula down & in ---relax. »
• Note: gr. 3 is given for full
ROM without upward rotation
of the scapula.
• Gr. 2 is given for partial range.
Testing and Measurements
Physical Therapy - Ms. I. Devreux
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Scapular Depression and Adduction:
Trapezius ( lower fibers)
Gr.4 – 5; Good & normal strength:
• Pt. as in gr. 2-3.
• Therapist applies one hand for
resistance on the lateral angle of
the scapula.
• Resistance: gr. 4 : moderate in an
outward + upward direction
throughout the ROM.
Grade 5 : Max. resistance + hold
at the end of ROM.
• Command: Try to pull your arm
slightly up and pull your scapula
down & in---(hold for gr.5)--relax. »
Testing and Measurements
Physical Therapy - Ms. I. Devreux
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Scapular Depression and Adduction:
Trapezius ( lower fibers)
• Grade 1 & 0 : Trace &
zero:
• Pt and therapist
position as in gr. 3 &
2 but one hand
palpates ms.
contraction between
the last thoracic
vertebrae & scapula.
Testing and Measurements
Physical Therapy - Ms. I. Devreux
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Another movement
Scapular adduction & downwards rotation:
Rhomboids.
Testing and Measurements
Physical Therapy - Ms. I. Devreux
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Scapular adduction & downwards rotation:
Rhomboids.
Rhomboid major & minor:
Origin:
• Major: spinous processes of 2nd
– 5th thoracic vertebrae.
• Minor: Ligamentum Nuchae.
• Spinous processes of C7 & T1.
Insertion:
• Major: Medial border of scapula
between the spine & inferior
angle .
• Minor: med. border and root of
spine of scapula.
Nerve: C4 C5.
Action: adducts & elevate the
scapula &rotate it so that the
glenoid cavity faces caudally.
Testing and Measurements
Physical Therapy - Ms. I. Devreux
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Scapular adduction & downwards rotation:
Rhomboids.
Accessory muscle : Trapezius (
adductor).
• ROM: similar to the distance
as for add. of the scapula: 3
to 4 fingers.
Limitation of ROM as for
scapular adduction:
• Tension of coronoid
ligament
( limits backward rot. of
scapula upon clavicle).
• Tension of pectoralis major
& minor & serratus ant. ms.
• Contact of the vertebral
border of scapula with spinal
musculature.
Testing and Measurements
Physical Therapy - Ms. I. Devreux
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Scapular adduction & downwards rotation:
Rhomboids.
Grade 3 testing procedure:
• Pt. : prone lying with
affected arm medially
rotated & adducted across
back & shoulders relaxed.
• Therapist: beside the
opposite shoulder.
• One hand is placed over the
opposite shoulder to
stabilize the thorax.
• Command: « Pull your arm
up & bring your scapula
down and in---relax. »
Testing and Measurements
Physical Therapy - Ms. I. Devreux
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Scapular adduction & downwards rotation:
Rhomboids.
Grade 4 & 5: Good – Normal:
• Pt in same position
(prone).
• Therapist applies resistance
on the scapula ‘s vertebral
border.
• Resistance: moderate (gr.4)
in an outward & downward
direction.
• Maximal resistance + hold at
end of Rom.
Testing and Measurements
Physical Therapy - Ms. I. Devreux
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Scapular adduction & downwards rotation:
Rhomboids.
Grade 2; Poor strength:
• Pt. Sitting on the treatment table with
the affected arm in the same position
in adduction.
• Therapist’s hand is on the affected
shoulder anteriorly & the other hand
is on the opposite scapula.
• Therapist then stabilizes the trunk
with pressure applied from both
hands.
• Command: » Bring your arm back &
your scapula in ---relax. »
Grade 1 & 0 : Trace and Zero
strength:
• One hand on opposite shoulder, the
other palpates at the angle formed
by the vertebral border of the
scapula & the lateral fibers of the
lower trapezius.Under the vertebral
border of the scapula.
Testing and Measurements
Physical Therapy - Ms. I. Devreux
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Scapular adduction & downwards rotation:
Rhomboids
Effets of weakness of the scapula adductor
depressor & downward rotator muscles:
• Weakness will cause the scapula to abduct &
the inferior angle to rotate outward.
• The strength of the adduction & extension of the
humerus is diminished by the loss of Rhomboids
fixation of the scapula.
• Ordinary function of the arm is affected less by
loss of Rhomboids than by loss of either
Trapezius or Serratus Anterior muscles.
Testing and Measurements
Physical Therapy - Ms. I. Devreux
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Scapular adduction & downwards rotation:
Rhomboids
Effets of contracture of the
scapula adductor
depressor & downward
rotator muscles:
• The scapula is drawn into a
position of adduction and
elevation.
• Contracture tends to
accompany paralysis or
weakness of Serratus
Anterior Muscle because
Rhomboids are direct Testing and Measurements
Physical Therapy - Ms. I. Devreux
opponents of the Serratus.
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THANK YOU
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Physical Therapy - Ms. I. Devreux
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