2011 Scapulothoracic and Scapulohumeral Exercises, A Narrative Review of Electromyographic Studies

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JHT READ FORCREDITARTICLE #204.

Scapulothoracic and Scapulohumeral Exercises:

A Narrative Review of ElectromyographicStudies

Mike Cricchio, MBA, OTR/L, CHTShands Hand and Upper Extremity, University of Florida,Gainesville, Florida

Cindy Frazer, DPT, MTCShands Hand and Upper Extremity, University of Florida,Gainesville, Florida

ABSTRACT:Study Design: Narrative review.Introduction: A well-constructed rehabilitation program of the

shoulder complex is critical to stabilizing the scapulothoracic andscapulohumeral joints while encouraging normal scapulohumeralrhythm. Review of the literature demonstrates a variety of scapu-lothoracic and glenohumeral conditioning exercises.

Purpose: To assist the occupational and physical therapist inprioritizing exercises for a shoulder conditioning program basedon a narrative review of electromyographic (EMG) studies of theshoulder.

Methods: The authors performed a comprehensive literaturesearch of approximately 250 articles describing shoulder (EMG)testing of the rotator cuff and periscapular musculature. Twenty-two articles were selected based on the authors inclusion criteria.The authors developed a flowsheet outliningeach exercise, startingand ending positions, principle muscle(s), and description of exer-cise. Exercises were assignedto twodifferent muscle groups:rotatorcuff or periscapular depending on the principle muscles activated.

Results: The 22 included articles provided an evidenced-basedlist of exercises aimed to efficiently and maximally recruit specificrotator cuff and periscapular musculature. Based on these 22 arti-cles, the authors were able to establisha useful series of exercises topromote glenohumeral stability and foster normal scapulohumeral

rhythm. Those exercises that elicited the highest maximum volun-tary isometric contraction recruitment and were cited to be criticalfor stability and scapulohumeral rhythm were selected for theexercise flow sheet.

Conclusions: This review provides a useful evidence-based toolto establish a practical shoulder exercise program.

Level of Evidence: Level 5.

J HAND THER. 2011;24:32234.

Mechanical causes of shoulder impingement com-monly relate to dysfunctional glenohumeral andscapulothoracic kinematics and weak or insufficientstabilizing musculature.1 During daily overheadactivity, both the rotator cuff and periscapular

musculature play a crucial role in stabilizing the

glenohumeral and scapulothoracic joints for effectivepain-free shoulder movements.

The mobility of the shoulder requires that therotator cuff musculature provide dynamic compres-sive forces to keep the humeral head seated in

the concave glenoid fossa.2e9 Absent or insufficientrotator cuff compressive forces result in superior mi-gration of the humeral head and often resultinsubse-quent narrowing of the subacromial space.7,10e14

Often, shoulder pain and impingement are thoughtto be the result of rotator cuff injury or weaknesswithout consideration of normal scapular positioningand kinematics. Review of the current literaturesuggests that scapulothoracic dyskinesis is a contrib-uting component to glenohumeral pathology.15,16

Scapulothoracic dyskinesis is defined as abnormalityin scapular motion and resting position and has been

SCIENTIFIC/CLINICAL ARTICLE

This manuscript was not adapted from a professional presentationgivenby the corresponding author, Mike Cricchio, at the 2010 TetonHand and Upper Extremity Conference. No grant or other financialsupport was provided for this manuscript.

Correspondence and reprint requests to Mike Cricchio, MBA,OTR/L, CHT, Shands Hand and Upper Extremity, Universityof Florida, 3450 Hull Rd, Gainesville, FL 32607; e-mail:.

0894-1130/$ - see front matter 2011 Hanley & Belfus, an imprintof Elsevier Inc. All rights reserved.

doi:10.1016/j.jht.2011.06.001

322 JOURNAL OF HAND THERAPY
mailto:[email protected]://dx.doi.org/10.1016/j.jht.2011.06.001http://dx.doi.org/10.1016/j.jht.2011.06.001mailto:[email protected]


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associated with several different types of patholo-gy.17e22 Some of these pathologies include disruptionof coupled scapulohumeral rhythm, abnormal ten-sion in the anterior inferior glenohumeral ligament,loss of subacromial space when the arm is in an ab-ducted position, and inhibition of supraspinatusactivity.18,23e25

Normal scapulohumeral rhythm requires properactivation of the scapular upward rotators.26e33 The

upward rotators of the scapula are the upper trape-zius (UT) and lower trapezius (LT) and the serratusanterior (SA) muscles.15,20 Collectively, these musclesare important in achieving full forward flexionandabduction osteokinematically.29 Warner et al.25 pre-sented evidence to suggest that shoulder impinge-ment is associated with scapular winging anddysfunction. The volume of the subacromial spaceduring shoulder elevation is thought to be maximizedwith proper scapular kinematics, thus reducing theincidence of shoulder external or internal impinge-ment of the rotator cuff.32,34,35 The greatest risk for

shoulder impingement is when the scapula is inter-nally rotated and anteriorly tilted; this risk is in-creased when performing abduction in the scapularplane with internal rotation (IR) (i.e., the emptycan position).36

The serratus anterior muscle produces scapularupward rotation, posterior tipping, and externalrotation (ER), thus preserving the subacromialspace.37 Research has linked weakness in theserratusanterior muscle to shoulder pathology.19,38e41 Surfaceelectromyographic (EMG) analysis suggests that pa-tients with shoulder impingement demonstrated anincreased EMG activity in the upper trapezius but de-creased activity in theserratus anterior muscles dur-ing shoulder elevation.19,29 Increased EMG activity inthe upper trapezius can be a contributing factor to an-terior tilt and excessive scapular elevation leading toa narrowing of the subacromial space. Restoration ofnormal scapulohumeral rhythm requires exercisesthat balance the upper, middle (MT), and lower tra-pezius and serratus anterior muscles.29

Consequently, balanced active participation of ro-tator cuff and scapulothoracic musculature are es-sential to produce proper motion and stabilitythrough the shoulder girdle.19,31,35,40,42,43 Therapist-

driven exercise programs built on evidence-basedknowledge of shoulder anatomy, biomechanics, andEMG studies are a vital part of creating shouldermuscle balance and constructing an effective exerciseprogram.44

Glousman45 noted that EMG studies have helpedto evaluate dynamic muscle activity and formulatethe basis for optimal rehabilitation programs. EMGanalysis identifies both relative intensity of muscleactivity and time during shoulder activity.45

Glousman45 states, The ability to analyze motionwith EMG has provided several tenets of shoulder

mechanics now excepted as common knowledge .EMG has helped to formulate a basis for optimaltreatment and prophylaxis of shoulder injuries.

A well-constructed rehabilitation program of theshoulder complex is critical to returning a patient

back to his or her prior level of function. Occupationaland physical therapists may be exposed to a variety ofglenohumeral and scapulothoracic conditioning ex-ercises throughout their career. Time and again these

exercises are implemented without specific regard toeffectiveness, shoulder girdle positioning, and/orcomprehensive review of the literature.

Determining which exercises are most advanta-geous for specific patients with a given shoulderpathology, although noteworthy, was not the in-tended aim of this review. Rather, the purpose ofthis review was to assist occupational and physicaltherapists in prioritizing exercises for a shoulderconditioning program based on a narrative reviewof EMG studies of the shoulder, irrespective of shoul-der pathology.

METHODS

The authors performed a literature search of articlesdescribing shoulder EMG testing of the rotator cuffand periscapular musculature. Approximately 250articles were found using the keywords human EMGshoulder exercises via various search engines andprofessional journals including Proquest, PubMed,Library and Information Resources Network, GalePower Search, Journal of Shoulder and Elbow Surgery,

Journal of Hand Therapy, Journal of Orthopaedics andSports Physical Therapy, British Journal of Sports

Medicine, Journal of Athletic Training, The AmericanJournal of Sports Medicine, Journal of Sports Medicine,Physical Therapy, Clinical Rehabilitation, PhysicalTherapy in Sport, andManual Therapy.

The articles were reviewed by two researchers todetermine which articles met the following inclusioncriteria: article must have been published within thepast 20 years, article must be in a peer-reviewed

journal, a controlled laboratory study or equivalentlevel of evidence of three or greater established,sample of adults with or without pathology, and

investigators used either needle and/or surfaceEMG. Furthermore, the study must be repeatable,

based on placement of electrodes and patient posi-tion for performing the desired exercise. The studymust also describe a single statistical analysis ormultiple analyses with correction to prevent types Iand II errors. The authors developed a flow sheet tooutline each exercise, starting and ending positions,principle muscle(s), and position. Exercises wereassigned to two different muscle groups: periscapu-lar or rotator cuff, depending on the principle mus-cles activated with each exercise.

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To be included in the review, all articles must havemet all inclusion criteria. If the reviewers disagreedon the inclusion criteria, a third reviewer was intro-duced to make the inclusion decision.

After review of the articles, the researchersdetermined that 22 articles that met the inclusioncriteria. The literature describing exercises thatelicited the highest maximum voluntary isometriccontraction (MVIC) of rotator cuff and periscapu-

lar musculature and were cited to be critical forstability and scapulohumeral rhythm were selectedfor the exercise program (Table 1).

RESULTS

The 22 included manuscripts were all experimentalor controlled laboratory studies. These experimentsprovided an evidenced-based list of exercises aimedto efficiently and maximally recruit specific rotatorcuff and periscapular musculature. Based on this

research, the authors were able to establish a usefulseries of exercises to promote glenohumeral stabilityand foster normal scapulohumeral rhythm.

Of the included articles, 12 described exercises tostrengthen or condition one or all the rotator cuffmuscles: subscapularis, infraspinatus, teres minor,and supraspinatus. Fourteen articles discussed exer-cises for the trapezius (upper, middle, or lower) andserratus anterior musculature. Two of the total 22articles discussed exercises for both glenohumeraland scapulothoracic musculature.

The exercises that produced the highest MVIC per

selected muscle and were cited to be critical forstability and scapulohumeral rhythm were selected

by the researchers to be included in the flow sheet ofexercises. Exercises were assigned to two differentmuscle groups: rotator cuff or periscapular, depend-ing on the principle muscles activated.

ROTATOR CUFF EXERCISES

Strength of the rotator cuff muscles is imperativeto optimal function of the glenohumeral joint.

Collectively, they keep the humeral head seatedtightly in the glenoid fossa during dynamic activitiespreventing superior translation of the humeralhead.2,14,15,46e48 The included articles note that thefollowing rotator cuff exercises elicited the highestMVIC: isometric external rotation46 side-lying exter-nal rotation,49 full can50 prone horizontalabduction(extension) at 1008 with external rotation,49,51 zero-position internalrotation,22 push-up plus,52 and thediagonal exercise52 (Table 2).

An optimal shoulder rehabilitation programshould consider the MVIC of the individual rotator

cuff muscles in concert with the actual and relativeglenohumeral and scapulothoracic muscle strength.Resisted isometric external rotation maximizes re-cruitment of the infraspinatus muscle while mini-mizing deltoid involvement when performed atlow-medium loads not exceeding 40% of MVIC.46

Reinold et al.49 noted that side-lying external rota-tion yielded the highest MVIC for infraspinatus andteres minor. Cools et al.17 further demonstrated that

the side-lying position for external rotation also min-imized upper trapezius firing with a low UT/LT ra-tio. Minimal activation of the UT is likely as a resultof the gravity-eliminated position and itsminimizedpostural role in the side-lying position.17 Therapistsshould avoid prescribing individuals with UT/LTimbalance exercises that include external rotation instanding due toexcessive postural activation of theupper trapezius.15,17,24,29,53,54

Specifically targeting individual rotator cuff mus-cles, while minimizing postural muscles and syner-gistic prime movers, can be challenging. Reinold

et al.

50

found that the full can position producedless deltoid activity and was the preferred positionto recruit and rehabilitate the supraspinatus muscle.

Horizontal abduction (extension)with external ro-tation as reported by Townsend et al.51 reveals a lowerUT/LT ratio than horizontal abduction (extension)without external rotation.17 Thus, horizontal abduc-tion (extension) with external rotation is a preferredexercise for conditioning of the supraspinatus musclefor two reasons: the highest MVIC of supraspinatus asdemonstrated by Townsend et al.51 and a low UT/LTratio.17 However, prone horizontal abduction (exten-sion) at 1008 with full external rotation produce higherlevels of deltoid involvement and may not be an ad-vantageous exercise for patients with poor dynamicshoulder stability secondary to superior humeralhead migration with deltoid activation.49

The zero-position internal rotation exercise dem-onstrated higher EMG subscapularis muscle activityand reduced pectoralis major activity due to theincreased shoulder abduction in the zero position.22

Decker et al.52 advised segmental training of the sub-scapularis muscle to address and recruit the upperand lower portions of the muscle. The push-up plusand diagonal exercises consistently produced the

highest EMG activity in both portions of the subscap-ularis muscle.52 Hess et al.55 noted that early activa-tion of the subscapularis relative to the other rotatorcuff muscles is also critical to the support and protec-tion of the glenohumeral joint.

PERISCAPULAR EXERCISES

To promote proper scapulohumeral rhythm,the scapular stabilizing musculature must be condi-tioned to allow for the smooth movement of the



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TABLE 1. Inclusion Criteria Data

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)

Bitter et al.46 (2007) 1 18 34e49 6 12 18 0 Surface 1

Cools et al.17 (2007) 2 45 19e22 20 25 45 0 Surface 5

Decker et al.56 (1999) 3 20 25e35 20 0 20 0 Surface 5

Decker et al.52 (2003) 4 15 23e32 9 6 15 0 Surface &

indwelling

5

De Mey et al.15 (2009) 5 30 21e27 14 16 3 0 Surface 5

Ebaugh et al.57 (2005) 6 20 18e30 10 10 20 0 Surface 5

Ekstron et al.28 (2003) 7 30 22e

46 10 2 3 0 Surface 3

Hardwick et al.30 (2006) 8 20 23e41 10 10 20 0 Surface 3

Hess et al.55 (2005) 9 23 24e41

22e41

23 0 11 12 Indwelling 3

Hintermeister et al.58 (1998) 10 19 24e36 19 0 19 0 Surface &

indwelling

2

Kibler et al.24 (2008) 11 39 23e35

24e38

9

13

9

8

18 11 Surface 2

Kinney et al.59 (2007) 12 32 18e35 13 19 32 0 Surface 1

OctobereDecember2011

325


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TABLE 1. (continued)

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)

Lehman et al.34 (2007) 13 10 25e27 10 0 10 0 Surface 3

Ludewig and Cook16 (2004) 14 30 18e50 7

6

12

5

19 11 Surface 5

Maenhout et al.54 (2009) 15 32 20e24 16 16 32 0 Surface 3, 5

Moseley et al.32 (1992) 16 9 22e34 7 2 9 0 Indwelling 1

Reinold et al.50 (2007) 17 22 19e34 15 7 22 0 Indwelling 5

Reinold et al.49 (2004) 18 10 22e38 5 5 10 0 Indwelling 10

Suenaga et al.22 (2003) 19 8 24e32 8 0 8 0 Surface &

indwelling

4

Townsend et al.51 (1991) 20 15 23e24 15 0 15 0 Indwelling 1

Uhl et al.60 (2003) 21 18 19e25 NA NA 18 0 Surface &

indwelling

3

Wise et al.61 (2004) 22 20 19e

23 NA NA 20 0 Surface &

indwelling

3

UT upper trapezius; MT middle trapezius; LT lower trapezius; SA serratus anterior; ER/IR external/internal rotation; EMG electrcontraction; NA not available.Bold test indicates cohort of subjects without pathology.

326

JOURNALOFHAND

THERAPY


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scapula and prevent scapular winging. The includedarticles noted that the following periscapular exer-cises elicited the highest MVIC: prone exten-sion,15,17,32 horizontal abduction (extension) at 908

with full external rotation,29 overhead arm raise at1258,29 inferior glide,24 lawnmower,24 push-upplus,56 dynamic hug,56 and wall slide.30,61 Theseexercises specifically target the serratus anterior andmiddle and lower trapezius muscles18 (Table 3).

Review of the 14 periscapular exercise articlesdescribes how conditioning and strengthening ofthe above-mentioned exercises is key to a balancedshoulder rehabilitation program. According toEkstrom et al.,29 the trapezius and serratus anteriormusculature are the most important for restoringnormal rhythm. However, poor serratus anterioractivation may be overpowered by the upper tra-pezius and cause additional pain in shoulderimpingement patients secondary to the upper trape-zius promoting excessive scapular elevation andanterior tilt.15,17,24,29,53,54,59 Therefore, the focus ofstrengthening the serratus anterior muscle appears

imperative if the goal is to decrease impingementpain.15,17,24,29,53,54,59

Consequently, before prescribing shoulder exer-cises, consideration must also be given to scapularmuscle balance.15,17,24,29,53,54,59 Specifically, the ratioof muscle strength between the UT, MT, LT, andSA muscles must be balanced.15,17,24,29,53,54,59 Coolset al.17 state, For patients with an imbalance inthe scapular muscles, selective activation of weakermuscle parts, with minimal activity in the hyper-active muscles, is an important component in thereduction of the imbalance . lack of activity in

the lower trapezius, middle trapezius, and serratusanterior frequently is combined with excessive useof the upper trapezius. Excessive activation of theupper trapezius with deceased control of the lowertrapezius and serratus anterior has been proposedas contributing to abnormal scapular motion.They suggest that selection of specific shoulder ex-ercises due to scapular dyskinesis should not solely

be based on absolute strength values but includemuscle balance ratios based on EMG analysis.17

They also state, The selection of appropriate exer-cises in the rehabilitation of scapular muscle perfor-mance depends on the actual strength of themuscles but also the relative strength of 1 musclein relation to another.17

Moseley et al.48 and Cools et al.17 both demon-strated high EMG activity of the middle trapeziuswith prone extension; Cools et al.17 further notedminimal upper trapezius activity with prone exten-sion and a corresponding low UT/MT ratio. Proneabduction (extension) with externalrotation at 90829

and the arm raise overhead at 125829 bothtarget the

middle and lower trapezius musculature.59The inferior glide is an isometric exercise that

primarily targets the lower trapezius and serratusanterior while emphasizing humeral head depres-sion and scapular retraction.18 The isometric low rowalso principally targets the lower trapezius and serra-tus anterior but emphasizes scapular external rota-tion and posterior tilt.18 Likewise, the lawnmowerrecruits the lower trapezius and serratus anteriorthrough a multijoint movement in which the serratusanterior works to maintain scapular retraction in anexternally rotated posture.18

TABLE 2. Rotator Cuff Exercises

Exercise Muscle(s) Position

Isometric external rotation46 Infraspinatus Seated, feet flat on floor, knees bent at 908, arm at side in neutral rotation,and elbow at 908 of flexion (40% maximum voluntary isometriccontraction to minimize deltoid recruitment)

Side-lying external rotation49 Infraspinatus, teresminor

Arm fully adducted to side and internally rotated, with elbow flexed at 908;patient then externally rotates the shoulder up toward the ceiling

Full can50 Supraspinatus Arm elevated to 308 abduction (scaption) with full glenohumeral external

rotationProne horizontal abduction(extension) at 1008 with full ER49,51

Supraspinatus Prone horizontal abduction (extension) at 1008 with full ER. Subject liftshand toward the ceiling

Zero-position internal rotation22 Subscapularis Zero rotation of the humerus, arm elevated to 1558, resistance appliedagainst internal rotation

Push-up plus52 Subscapularis(upper & lower)

Subject prone with hands shoulder width apart and chest near the ground;subject then extends elbows to a standard push-up position, thencontinue to rise up by protracting the scapula

Diagonal exercise52 Subscapularis(upper & lower)

Standing, knees slightly bent, feet shoulder width apart in a split stance,handle of elastic resistance device grasped at shoulder height withelbow slightly flexed and humerus in neutral position, abducted to 908;the subject then horizontally flexes, adducts, and internally rotateshumerus until hand reaches the opposite anterior superior iliac spine

ER external rotation.



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The exercises (push-up plus, dynamic hug, andwall slide) that elicited the greatest amount ofserratus anterior muscle activity were those thatmaintained an upwardly rotated and protractedscapula.56 It is important to note that the highestlevel of serratus anterior EMG activity can beachievedin a range of motion below 908 of humeralelevation.56 Clinically, this is important with shoul-der that presents with impingement and/or scapu-

lar winging in which case the standard push-upplus exercises are optimal, as it yields a lowUT/SA ratio.53,56 The standard push-up plus exer-cise produces minimal upper trapezius activationand maximum activation of the serratus anteriormuscle.42

DISCUSSION

This narrative review synthesizes a group ofevidence-based exercises that focused on stabilizing

the scapulothoracic and scapulohumeral joints whilefostering scapulohumeral rhythm. The EMG datafurther provide empirical evidence to suggest a seriesof shoulder exercises based on MVIC of individualand collective rotator cuff muscles.

It is the authors hope that the series of exercisesoutlined (Appendix 1) will assist occupational andphysical therapists in selecting a program that willensure balance between rotator cuff and periscapu-lar musculature while promoting proper scapulohu-meral and scapulothoracic rhythm. Specifically, thesuggested exercises are aimed to promote strength,

balance, and coordination between the principalscapular rotators, the UTand SA muscles, and therotator cuff musculature.32,51,56 Decker et al.56 state,A fatigued serratus anterior muscle will reducescapular rotation and protraction and will allowthe humeral head to translate anteriorly and superi-orly, possibly leading to secondary impingementand rotator cuff tears. According to Ludewig andCook,16 For patients with an imbalance of UT toSA activation, an exercise that demonstrates a lowUT/SA ratio would be an important component ofrehabilitation to allow selective SA strengtheningand reduction of the imbalance. Consequently, the

authors suggest that priority be placed on shoulderexercises that promote a low UT/SA, UT/LT, andUT/MT ratios. Some reviewed articles describedseveral rotator cuff and periscapular exercises thatyielded high EMG results but promoted either pos-tural recruitment or high activation of the upper tra-pezius; these exercises were not selected as exercisesto be included in Appendix 1. Additionally, theauthors also recommend exercises that produce alow UT/LT ratio during specific rotator cuff exer-cises (i.e., side-lying ER and prone horizontal abduc-tion with ER).17

TABLE

3.

PeriscapularExercises

Exercise

Muscle(s)

Position

Proneextension

15,

17,3

2

Middletrapezius

Prones

houlderextensionwithelbowinfullextension

Horizontalextension(abduction)

withexternalrotationat90

8

29

Middletrapezius

Proneh

orizontalabductionat90

8

withfullER.

Overheadarmraiseat125829

Middleandlowtrapezius

Proneh

orizontalabduction(extension)at1258w

ithfullER.

Inferiorglide2

4

Lowtrapezius,serratus

anterior

Seatedwitharmabductedto90

8

,wristneutralp

osition,

elbowextended,

andfistclenchedonafullsupportivesurface.

Applypressureinanadductiondirectionand

inferiorlydepressthescapula.

Isometriclowrow

24


anterior

Subject

standsinfrontofanimmovablesurface.

Thepatientplaceshandontheedgeofthesurfacewiththepalmfacing

poste

riorly.Applypressuretothesurface;retractanddepressthescapula.

Lawnmower

24


anterior

Startwithtrunkflexedandrotatedtotheoppos

itesidefromtheaffectedarmatthecontralateralpatella.

Rotatetrunk

towardaffectedarm,

whileextendingthehip

andtrunktovertical.Affectedarmthen

simultaneouslyretractsthe

scapu

lawithelbowflexed.

Push-upplus5

6

Serratusanterior

Subject

pronewithhandsshoulderwidthapartandchestneartheground;subjectthenextendselbowstoastandardpush-

upposition,

thencontinuetoriseupbyprotractingthescapula.

Dynamichug

56

Serratusanterior

Horizontalflexionofhumerusataconstant60

8ofhumeralelevationwhilehandsfollowanimaginaryarcuntilmaximum

protractionisattained.

Wallslide3

0,6

1

Serratusanterior

Subject

standsfacingwallwithdominantfootatthebaseofthewallwithoppositefootshoulderwidthandbehind

dominantfoot.Ulnarportionofarmsinconta

ctwithsmoothwallwithshoulderandelbowflexedat90

8

;subject

instru

ctedtoslideforearmsupanddownthe

wall.

ER

externalrotation.



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There were two principal limitations to this study.One, this study reviewed a limited number of articles.The inclusion criteria set by the researchers preventedmany shoulder exercise EMG articles from beingincluded. However, these stringent criteria alsoaddedvalidity and repeatability to the study. Second, EMGelectrode placement can migrate during muscle ac-tivityyielding relatively poor reproducibility betweentesters leading to divergent data between studies.56 In

addition, results from surface and fine-needle EMGcan be marked depending on the muscle tested.56

CONCLUSION

The exercises discussed in the 22 articles provideoccupational and physical therapists with a variety ofscapulothoracic and glenohumeral conditioning exer-cises. These articles detail patient positioning, MVIC,arc of movement, and other measures of reliability. Asa result, this narrative review empowers the therapistswith a useful evidence-based tool to establish a prac-

tical evidence-based shoulder exercise program.A follow-up article detailing priority, progression,

and implementation of the described shoulder exer-cises would further offer the occupational or physicaltherapist a simple evidence-based tool to establishand progress patients through an evidence-basedshoulder exercise program. A controlled study todetermine which exercises advance scapular kine-matics, and are most advantageous for specificpatients with a given shoulder pathology, may beanother potential useful tool in the future.

Acknowledgments

The authors would like to thank Shands Hand and UpperExtremity for their support of this article and the followingindividuals for their individual and collective contribu-tions: Thomas Wright, MD, Department of Orthopedic,University of Florida, Gainesville, for critical review;Megan Schneider, MOT for extensive research and litera-ture review, Brian Laney, OTR/L, CHT, Shands Hand andUpper Extremity, Gainesville, for assistance with format-ting of photographs and exercise spreadsheet; Jack Hurov,PhD, PT, CHT, Shands Hand and Upper Extremity,Gainesville, for research design and editing; and DanielNadler for allowing us to take photographs demonstratingthe starting and ending position of each exercise.

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APPENDIX 1Exercise Starting Position Ending Position Principle Muscle(s) Muscle Group

Isometric External Rotation4 Rotator Cuff Infraspinatus

Sidelying External Rotation55 Infraspinatus Rotator Cuff Teres Minor

Full Can54 Rotator Cuff Supraspinatus

Prone horizontal abduction (extension)@ 100 degrees with full ER55,62

Rotator Cuff Supraspinatus

Zero-position IR61 Rotator Cuff Subscapularis

Push-up Plus10 Rotator Cuff Subscapularis


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APPENDIX (Continued )

Exercise Starting Position Ending Position Principle Muscle(s) Muscle Group

Diagonal Exercise10 Rotator Cuff Subscapularis

Prone extension6,11,48 Periscapular Middle Trapezius

Horizontal Extension with ER @ 90 degrees15 Middle Trapezius Periscapular Lower Trapezius

Inferior Glide29 Serratus Anterior Periscapular Lower Trapezius

Isometric Low Row29 Serratus Anterior Periscapular Lower Trapezius

Lawnmower29 Serratus Anterior Periscapular Lower Trapezius

332

JOURNALOFHAND

THERAPY


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Overhead Arm Raise @ 125 degrees15 Periscapular Middle TrapeziusLower Trapezius

Push-up Plus9 Serratus Anterior Periscapular Lower Trapezius

Wall Slide22,71 Periscapular Serratus Anterior

Dynamic Hug9 Periscapular Serratus Anterior


333


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JHT Read for CreditQuiz: Article #204

Record your answers on the Return Answer Formfound on the tear-out coupon at the back of thisissue or to complete online and use a credit card,go to JHTReadforCredit.com. There is only onebest answer for each question.

#1. Which of the following is not a function of the ser-ratus anterior muscle?a. scapular external rotationc. scapular upward rotation

c. scapular and glenohumeral external rotationd. scapular posterior tipping

#2. The upward rotators of the scapula area. serratus anterior and lower trapezius

b. rhomboid major and minorc. teres major and upper trapeziusd. middle trapezius and rhomboid major

#3. Scapulothoracic dyskinesis is best described asa. posterior scapular tilt

b. abnormalities in scapular motionc. abnormalities in scapular resting positiond. both b & c

#4. The authors recommend shoulder exercises thatpromotes a lowa. LT/UT ratio

b. SA/UT ratioc. UT/SA ratiod. SA/LT ratio

#5. A fatigued or de-conditioned serratus anterior

muscle will reducea. scapular retraction

b. scapular protractionc. scapular internal rotationd. scapular downward rotation

When submitting to the HTCC for re-certification,please batch your JHT RFC certificates in groupsof 3 or more to get full credit.


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2011 Scapulothoracic and Scapulohumeral Exercises, A Narrative Review of Electromyographic Studies