2011 Scapulothoracic and Scapulohumeral Exercises, A Narrative Review of Electromyographic Studies
2011 Scapulothoracic and Scapulohumeral Exercises, A Narrative Review of Electromyographic Studies
2011 Scapulothoracic and Scapulohumeral Exercises, A Narrative Review of Electromyographic Studies
JHT READ
FOR
322
ABSTRACT:
Study Design: Narrative review.
Introduction: A well-constructed rehabilitation program of the
shoulder complex is critical to stabilizing the scapulothoracic and
scapulohumeral joints while encouraging normal scapulohumeral
rhythm. Review of the literature demonstrates a variety of scapulothoracic and glenohumeral conditioning exercises.
Purpose: To assist the occupational and physical therapist in
prioritizing exercises for a shoulder conditioning program based
on a narrative review of electromyographic (EMG) studies of the
shoulder.
Methods: The authors performed a comprehensive literature
search of approximately 250 articles describing shoulder (EMG)
testing of the rotator cuff and periscapular musculature. Twentytwo articles were selected based on the authors inclusion criteria.
The authors developed a flow sheet outlining each exercise, starting
and ending positions, principle muscle(s), and description of exercise. Exercises were assigned to two different muscle groups: rotator
cuff or periscapular depending on the principle muscles activated.
Results: The 22 included articles provided an evidenced-based
list of exercises aimed to efficiently and maximally recruit specific
rotator cuff and periscapular musculature. Based on these 22 articles, the authors were able to establish a useful series of exercises to
promote glenohumeral stability and foster normal scapulohumeral
rhythm. Those exercises that elicited the highest maximum voluntary isometric contraction recruitment and were cited to be critical
for stability and scapulohumeral rhythm were selected for the
exercise flow sheet.
Conclusions: This review provides a useful evidence-based tool
to establish a practical shoulder exercise program.
Level of Evidence: Level 5.
J HAND THER. 2011;24:32234.
associated with several different types of pathology.17e22 Some of these pathologies include disruption
of coupled scapulohumeral rhythm, abnormal tension in the anterior inferior glenohumeral ligament,
loss of subacromial space when the arm is in an abducted position, and inhibition of supraspinatus
activity.18,23e25
Normal scapulohumeral rhythm requires proper
activation of the scapular upward rotators.26e33 The
upward rotators of the scapula are the upper trapezius (UT) and lower trapezius (LT) and the serratus
anterior (SA) muscles.15,20 Collectively, these muscles
are important in achieving full forward flexion and
abduction osteokinematically.29 Warner et al.25 presented evidence to suggest that shoulder impingement is associated with scapular winging and
dysfunction. The volume of the subacromial space
during shoulder elevation is thought to be maximized
with proper scapular kinematics, thus reducing the
incidence of shoulder external or internal impingement of the rotator cuff.32,34,35 The greatest risk for
shoulder impingement is when the scapula is internally rotated and anteriorly tilted; this risk is increased when performing abduction in the scapular
plane with internal rotation (IR) (i.e., the empty
can position).36
The serratus anterior muscle produces scapular
upward rotation, posterior tipping, and external
rotation (ER), thus preserving the subacromial
space.37 Research has linked weakness in the serratus
anterior muscle to shoulder pathology.19,38e41 Surface
electromyographic (EMG) analysis suggests that patients with shoulder impingement demonstrated an
increased EMG activity in the upper trapezius but decreased activity in the serratus anterior muscles during shoulder elevation.19,29 Increased EMG activity in
the upper trapezius can be a contributing factor to anterior tilt and excessive scapular elevation leading to
a narrowing of the subacromial space. Restoration of
normal scapulohumeral rhythm requires exercises
that balance the upper, middle (MT), and lower trapezius and serratus anterior muscles.29
Consequently, balanced active participation of rotator cuff and scapulothoracic musculature are essential to produce proper motion and stability
through the shoulder girdle.19,31,35,40,42,43 Therapistdriven exercise programs built on evidence-based
knowledge of shoulder anatomy, biomechanics, and
EMG studies are a vital part of creating shoulder
muscle balance and constructing an effective exercise
program.44
Glousman45 noted that EMG studies have helped
to evaluate dynamic muscle activity and formulate
the basis for optimal rehabilitation programs. EMG
analysis identifies both relative intensity of muscle
activity and time during shoulder activity.45
Glousman45 states, The ability to analyze motion
with EMG has provided several tenets of shoulder
METHODS
The authors performed a literature search of articles
describing shoulder EMG testing of the rotator cuff
and periscapular musculature. Approximately 250
articles were found using the keywords human EMG
shoulder exercises via various search engines and
professional journals including Proquest, PubMed,
Library and Information Resources Network, Gale
Power Search, Journal of Shoulder and Elbow Surgery,
Journal of Hand Therapy, Journal of Orthopaedics and
Sports Physical Therapy, British Journal of Sports
Medicine, Journal of Athletic Training, The American
Journal of Sports Medicine, Journal of Sports Medicine,
Physical Therapy, Clinical Rehabilitation, Physical
Therapy in Sport, and Manual Therapy.
The articles were reviewed by two researchers to
determine which articles met the following inclusion
criteria: article must have been published within the
past 20 years, article must be in a peer-reviewed
journal, a controlled laboratory study or equivalent
level of evidence of three or greater established,
sample of adults with or without pathology, and
investigators used either needle and/or surface
EMG. Furthermore, the study must be repeatable,
based on placement of electrodes and patient position for performing the desired exercise. The study
must also describe a single statistical analysis or
multiple analyses with correction to prevent types I
and II errors. The authors developed a flow sheet to
outline each exercise, starting and ending positions,
principle muscle(s), and position. Exercises were
assigned to two different muscle groups: periscapular or rotator cuff, depending on the principle muscles activated with each exercise.
OctobereDecember 2011 323
RESULTS
The 22 included manuscripts were all experimental
or controlled laboratory studies. These experiments
provided an evidenced-based list of exercises aimed
to efficiently and maximally recruit specific rotator
cuff and periscapular musculature. Based on this
research, the authors were able to establish a useful
series of exercises to promote glenohumeral stability
and foster normal scapulohumeral rhythm.
Of the included articles, 12 described exercises to
strengthen or condition one or all the rotator cuff
muscles: subscapularis, infraspinatus, teres minor,
and supraspinatus. Fourteen articles discussed exercises for the trapezius (upper, middle, or lower) and
serratus anterior musculature. Two of the total 22
articles discussed exercises for both glenohumeral
and scapulothoracic musculature.
The exercises that produced the highest MVIC per
selected muscle and were cited to be critical for
stability and scapulohumeral rhythm were selected
by the researchers to be included in the flow sheet of
exercises. Exercises were assigned to two different
muscle groups: rotator cuff or periscapular, depending on the principle muscles activated.
PERISCAPULAR EXERCISES
To promote proper scapulohumeral rhythm,
the scapular stabilizing musculature must be conditioned to allow for the smooth movement of the
Author (Yr)
Article
Count
Sample
Size
Subject
Age Range
(Yr)
No. of Male
Subjects
No. of
Female
Subjects
No. Subjects
without
Pathology
No. Subjects
with Pathology
EMG
Methodology
No. of
MVICs Trials
(per Muscle)
Description of
Muscle/Exercise
Trials(s)
46
(2007)
18
34e49
12
18
Surface
17
(2007)
45
19e22
20
25
45
Surface
20
25e35
20
20
Surface
15
23e32
15
Surface &
indwelling
Isometric
30
21e27
14
16
Surface
Concentric
20
18e30
10
10
20
Surface
Isometric
30
22e46
10
Surface
Concentric
20
23e41
10
10
20
Surface
Concentric
23
24e41
22e41
23
11
12
Indwelling
Concentric
10
19
24e36
19
19
Surface &
indwelling
Isometric
concentric
11
39
23e35
24e38
9
13
9
8
18
11
Surface
Concentric
12
32
18e35
13
19
32
Surface
Concentric
Isometric
Eccentric
Bitter et al.
Cools et al.
Outcomes/Conclusions
326
JOURNAL OF HAND THERAPY
TABLE 1. (continued)
No. of
Female
Subjects
No. Subjects
without
Pathology
No. Subjects
with Pathology
No. of
MVICs Trials
(per Muscle)
Description of
Muscle/Exercise
Trials(s)
Article
Count
Sample
Size
Subject
Age Range
(Yr)
13
10
25e27
10
10
Surface
Concentric
Isometric
14
30
18e50
7
6
12
5
19
11
Surface
Isometric
15
32
20e24
16
16
32
Surface
3, 5
Isometric
16
22e34
Indwelling
Concentric
Eccentric
Isometric
17
22
19e34
15
22
Indwelling
Concentric
Eccentric
Isometric
18
10
22e38
10
Indwelling
10
Concentric
Eccentric
Isometric
19
24e32
Surface &
indwelling
20
15
23e24
15
15
Indwelling
Concentric
Eccentric
Isometric
Concentric
Eccentric
Isometric
21
18
19e25
NA
NA
18
Surface &
indwelling
Isometric
22
20
19e23
NA
NA
20
Surface &
indwelling
Concentric
Eccentric
Isometric
Author (Yr)
34
Lehman et al.
(2007)
No. of Male
Subjects
EMG
Methodology
Outcomes/Conclusions
Added unstable support surface to
push-up variations does not
increase activation of
scapulothoracic or glenohumeral
muscles
Push-up plus is an optimal exercise in
cases of overactive UT or imbalance
in SA
In cases of scapular imbalance,
exercises with a low UT/SA ratio
are preferable
To ensure that scapular muscles are
not neglected, the following
exercises are recommended:
scaption, rowing, push-up with
plus, and press-up
The full can exercise may be the
optimal position to recruit the
supraspinatus and minimize
middle deltoid recruitment
Selection of ER exercises may be based
on the higher levels of EMG activity
of infraspinatus and teres minor as
well as concomitant activity of
supraspinatus and deltoid muscles
IR at the zero position may selectively
exercise the subscapularis
Scaption in IR or flexion, horizontal
abduction (extension) in ER, and
press-up yielded high levels of
EMG activity
Increasing upper extremity weight
bearing demands more from
shoulder musculature
An evidence-based, logical
progression from low to high
demand shoulder exercises exists
UT upper trapezius; MT middle trapezius; LT lower trapezius; SA serratus anterior; ER/IR external/internal rotation; EMG electromyograpy, MVIC maximum voluntary isometric
contraction; NA not available.
Bold test indicates cohort of subjects without pathology.
Muscle(s)
46
Infraspinatus
Infraspinatus, teres
minor
Supraspinatus
Full can50
Prone horizontal abduction
(extension) at 1008 with full ER49,51
Zero-position internal rotation22
Supraspinatus
Push-up plus52
Subscapularis
(upper & lower)
Diagonal exercise52
Subscapularis
(upper & lower)
Subscapularis
Position
Seated, feet flat on floor, knees bent at 908 , arm at side in neutral rotation,
and elbow at 908 of flexion (40% maximum voluntary isometric
contraction to minimize deltoid recruitment)
Arm fully adducted to side and internally rotated, with elbow flexed at 908 ;
patient then externally rotates the shoulder up toward the ceiling
Arm elevated to 308 abduction (scaption) with full glenohumeral external
rotation
Prone horizontal abduction (extension) at 1008 with full ER. Subject lifts
hand toward the ceiling
Zero rotation of the humerus, arm elevated to 1558 , resistance applied
against internal rotation
Subject prone with hands shoulder width apart and chest near the ground;
subject then extends elbows to a standard push-up position, then
continue to rise up by protracting the scapula
Standing, knees slightly bent, feet shoulder width apart in a split stance,
handle of elastic resistance device grasped at shoulder height with
elbow slightly flexed and humerus in neutral position, abducted to 908 ;
the subject then horizontally flexes, adducts, and internally rotates
humerus until hand reaches the opposite anterior superior iliac spine
ER external rotation.
Serratus anterior
Serratus anterior
Dynamic hug56
Wall slide30,61
DISCUSSION
ER external rotation.
Serratus anterior
Lawnmower24
Push-up plus56
Prone extension
Horizontal extension (abduction)
with external rotation at 908 29
Overhead arm raise at 1258 29
Inferior glide24
Position
Exercise
15,17,32
Muscle(s)
328
CONCLUSION
The exercises discussed in the 22 articles provide
occupational and physical therapists with a variety of
scapulothoracic and glenohumeral conditioning exercises. These articles detail patient positioning, MVIC,
arc of movement, and other measures of reliability. As
a result, this narrative review empowers the therapists
with a useful evidence-based tool to establish a practical evidence-based shoulder exercise program.
A follow-up article detailing priority, progression,
and implementation of the described shoulder exercises would further offer the occupational or physical
therapist a simple evidence-based tool to establish
and progress patients through an evidence-based
shoulder exercise program. A controlled study to
determine which exercises advance scapular kinematics, and are most advantageous for specific
patients with a given shoulder pathology, may be
another potential useful tool in the future.
Acknowledgments
The authors would like to thank Shands Hand and Upper
Extremity for their support of this article and the following
individuals for their individual and collective contributions: Thomas Wright, MD, Department of Orthopedic,
University of Florida, Gainesville, for critical review;
Megan Schneider, MOT for extensive research and literature review, Brian Laney, OTR/L, CHT, Shands Hand and
Upper Extremity, Gainesville, for assistance with formatting of photographs and exercise spreadsheet; Jack Hurov,
PhD, PT, CHT, Shands Hand and Upper Extremity,
Gainesville, for research design and editing; and Daniel
Nadler for allowing us to take photographs demonstrating
the starting and ending position of each exercise.
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APPENDIX 1
Exercise
Starting Position
Principle Muscle(s)
Muscle Group
Description
Infraspinatus
Rotator Cuff
Infraspinatus
Teres Minor
Rotator Cuff
Full Can54
Supraspinatus
Rotator Cuff
Supraspinatus
Rotator Cuff
Zero-position IR61
Subscapularis
Rotator Cuff
Push-up Plus10
Subscapularis
Rotator Cuff
Ending Position
(Continued)
332
JOURNAL OF HAND THERAPY
APPENDIX (Continued )
Exercise
Principle Muscle(s)
Muscle Group
Description
Subscapularis
Rotator Cuff
Prone extension6,11,48
Middle Trapezius
Periscapular
Middle Trapezius
Lower Trapezius
Periscapular
Inferior Glide29
Serratus Anterior
Lower Trapezius
Periscapular
Serratus Anterior
Lower Trapezius
Periscapular
Lawnmower29
Serratus Anterior
Lower Trapezius
Periscapular
10
Diagonal Exercise
Starting Position
Ending Position
Middle Trapezius
Lower Trapezius
Periscapular
Push-up Plus9
Serratus Anterior
Lower Trapezius
Periscapular
Wall Slide22,71
Serratus Anterior
Periscapular
Dynamic Hug9
Serratus Anterior
Periscapular
334