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SCIENTIFIC/CLINICAL ARTICLE

JHT READ

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CREDIT ARTICLE #204.

Scapulothoracic and Scapulohumeral Exercises:


A Narrative Review of Electromyographic
Studies
Mike Cricchio, MBA, OTR/L, CHT
Shands Hand and Upper Extremity, University of Florida,
Gainesville, Florida

Cindy Frazer, DPT, MTC


Shands Hand and Upper Extremity, University of Florida,
Gainesville, Florida

Mechanical causes of shoulder impingement commonly relate to dysfunctional glenohumeral and


scapulothoracic kinematics and weak or insufficient
stabilizing musculature.1 During daily overhead
activity, both the rotator cuff and periscapular
musculature play a crucial role in stabilizing the
This manuscript was not adapted from a professional presentation
given by the corresponding author, Mike Cricchio, at the 2010 Teton
Hand and Upper Extremity Conference. No grant or other financial
support was provided for this manuscript.
Correspondence and reprint requests to Mike Cricchio, MBA,
OTR/L, CHT, Shands Hand and Upper Extremity, University
of Florida, 3450 Hull Rd, Gainesville, FL 32607; e-mail:
<criccm@shands.ufl.edu>.
0894-1130/$ - see front matter 2011 Hanley & Belfus, an imprint
of Elsevier Inc. All rights reserved.
doi:10.1016/j.jht.2011.06.001

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JOURNAL OF HAND THERAPY

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.

glenohumeral and scapulothoracic joints for effective


pain-free shoulder movements.
The mobility of the shoulder requires that the
rotator cuff musculature provide dynamic compressive forces to keep the humeral head seated in
the concave glenoid fossa.2e9 Absent or insufficient
rotator cuff compressive forces result in superior migration of the humeral head and often result in subsequent narrowing of the subacromial space.7,10e14
Often, shoulder pain and impingement are thought
to be the result of rotator cuff injury or weakness
without consideration of normal scapular positioning
and kinematics. Review of the current literature
suggests that scapulothoracic dyskinesis is a contributing component to glenohumeral pathology.15,16
Scapulothoracic dyskinesis is defined as abnormality
in scapular motion and resting position and has been

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

mechanics now excepted as common knowledge .


EMG has helped to formulate a basis for optimal
treatment and prophylaxis of shoulder injuries.
A well-constructed rehabilitation program of the
shoulder complex is critical to returning a patient
back to his or her prior level of function. Occupational
and physical therapists may be exposed to a variety of
glenohumeral and scapulothoracic conditioning exercises throughout their career. Time and again these
exercises are implemented without specific regard to
effectiveness, shoulder girdle positioning, and/or
comprehensive review of the literature.
Determining which exercises are most advantageous for specific patients with a given shoulder
pathology, although noteworthy, was not the intended aim of this review. Rather, the purpose of
this review was to assist occupational and physical
therapists in prioritizing exercises for a shoulder
conditioning program based on a narrative review
of EMG studies of the shoulder, irrespective of shoulder pathology.

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

To be included in the review, all articles must have


met all inclusion criteria. If the reviewers disagreed
on the inclusion criteria, a third reviewer was introduced to make the inclusion decision.
After review of the articles, the researchers
determined that 22 articles that met the inclusion
criteria. The literature describing exercises that
elicited the highest maximum voluntary isometric
contraction (MVIC) of rotator cuff and periscapular musculature and were cited to be critical for
stability and scapulohumeral rhythm were selected
for the exercise program (Table 1).

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.

ROTATOR CUFF EXERCISES


Strength of the rotator cuff muscles is imperative
to optimal function of the glenohumeral joint.
Collectively, they keep the humeral head seated
tightly in the glenoid fossa during dynamic activities
preventing superior translation of the humeral
head.2,14,15,46e48 The included articles note that the
following rotator cuff exercises elicited the highest
MVIC: isometric external rotation46 side-lying external rotation,49 full can50 prone horizontal abduction
(extension) at 1008 with external rotation,49,51 zeroposition internal rotation,22 push-up plus,52 and the
diagonal exercise52 (Table 2).
An optimal shoulder rehabilitation program
should consider the MVIC of the individual rotator
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cuff muscles in concert with the actual and relative


glenohumeral and scapulothoracic muscle strength.
Resisted isometric external rotation maximizes recruitment of the infraspinatus muscle while minimizing deltoid involvement when performed at
low-medium loads not exceeding 40% of MVIC.46
Reinold et al.49 noted that side-lying external rotation yielded the highest MVIC for infraspinatus and
teres minor. Cools et al.17 further demonstrated that
the side-lying position for external rotation also minimized upper trapezius firing with a low UT/LT ratio. Minimal activation of the UT is likely as a result
of the gravity-eliminated position and its minimized
postural role in the side-lying position.17 Therapists
should avoid prescribing individuals with UT/LT
imbalance exercises that include external rotation in
standing due to excessive postural activation of the
upper trapezius.15,17,24,29,53,54
Specifically targeting individual rotator cuff muscles, while minimizing postural muscles and synergistic prime movers, can be challenging. Reinold
et al.50 found that the full can position produced
less deltoid activity and was the preferred position
to recruit and rehabilitate the supraspinatus muscle.
Horizontal abduction (extension) with external rotation as reported by Townsend et al.51 reveals a lower
UT/LT ratio than horizontal abduction (extension)
without external rotation.17 Thus, horizontal abduction (extension) with external rotation is a preferred
exercise for conditioning of the supraspinatus muscle
for two reasons: the highest MVIC of supraspinatus as
demonstrated by Townsend et al.51 and a low UT/LT
ratio.17 However, prone horizontal abduction (extension) at 1008 with full external rotation produce higher
levels of deltoid involvement and may not be an advantageous exercise for patients with poor dynamic
shoulder stability secondary to superior humeral
head migration with deltoid activation.49
The zero-position internal rotation exercise demonstrated higher EMG subscapularis muscle activity
and reduced pectoralis major activity due to the
increased shoulder abduction in the zero position.22
Decker et al.52 advised segmental training of the subscapularis muscle to address and recruit the upper
and lower portions of the muscle. The push-up plus
and diagonal exercises consistently produced the
highest EMG activity in both portions of the subscapularis muscle.52 Hess et al.55 noted that early activation of the subscapularis relative to the other rotator
cuff muscles is also critical to the support and protection of the glenohumeral joint.

PERISCAPULAR EXERCISES
To promote proper scapulohumeral rhythm,
the scapular stabilizing musculature must be conditioned to allow for the smooth movement of the

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)

Description of
Muscle/Exercise
Trials(s)

46

(2007)

18

34e49

12

18

Surface

17

(2007)

45

19e22

20

25

45

Surface

Decker et al.56 (1999)

20

25e35

20

20

Surface

10%, 40%, 70%


of MVIC
Concentric
Isometric
Eccentric
Isometric

Decker et al.52 (2003)

15

23e32

15

Surface &
indwelling

Isometric

De Mey et al.15 (2009)

30

21e27

14

16

Surface

Concentric

Ebaugh et al.57 (2005)

20

18e30

10

10

20

Surface

Isometric

Ekstron et al.28 (2003)

30

22e46

10

Surface

Concentric

Hardwick et al.30 (2006)

20

23e41

10

10

20

Surface

Concentric

Hess et al.55 (2005)

23

24e41
22e41

23

11

12

Indwelling

Concentric

Hintermeister et al.58 (1998)

10

19

24e36

19

19

Surface &
indwelling

Isometric
concentric

Kibler et al.24 (2008)

11

39

23e35
24e38

9
13

9
8

18

11

Surface

Concentric

Kinney et al.59 (2007)

12

32

18e35

13

19

32

Surface

Concentric
Isometric
Eccentric

Bitter et al.

Cools et al.

Outcomes/Conclusions

OctobereDecember 2011 325

Infraspinatus maximized with


isometric ER ,40% MVIC
Suggest the use of side-lying & prone
positioning to activate LT and MT
with minimal activation of UT
Based on eight SA exercises ,908 of
humeral elevation, the push-up
plus, dynamic hug, and SA punch
yielded the greatest SA activation
Push-up with plus and diagonal
exercises yielded the greatest
activation of upper and lower
subscapularis muscle fibers
Prone extension and prone horizontal
abduction (extension) with ER
promote activation and timing of
MT & LT relative to UT
Decreased levels of periscapular
muscle activation alter
scapulothoracic kinematics
Greatest UT activation with shoulder
shrug; greatest MT best activation
with shoulder horizontal abduction
(extension) with ER and overhead
arm raise in prone; most LT
activation overhead arm raise in
prone
SA activation during the wall slide (at
or above 908 ) is not significantly
different than the SA activation
during the plus phase of push-up
plus
Activation of subscapularis before
onset of other cuff muscles may be
preprogrammed for joint support
7 elastic band exercises effectively
active rotator cuff and peri-scapular
muscles
Exercises tested serve as stable base to
establish scapular control and
glenohumeral function
MT & LT demonstrate the greatest
activation during 908 and 1258 of
glenohumeral joint abduction
compared with 1608
(Continued on next page)

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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

Ludewig and Cook16 (2004)

14

30

18e50

7
6

12
5

19

11

Surface

Isometric

Maenhout et al.54 (2009)

15

32

20e24

16

16

32

Surface

3, 5

Isometric

Moseley et al.32 (1992)

16

22e34

Indwelling

Concentric
Eccentric
Isometric

Reinold et al.50 (2007)

17

22

19e34

15

22

Indwelling

Concentric
Eccentric
Isometric

Reinold et al.49 (2004)

18

10

22e38

10

Indwelling

10

Concentric
Eccentric
Isometric

Suenaga et al.22 (2003)

19

24e32

Surface &
indwelling

Townsend et al.51 (1991)

20

15

23e24

15

15

Indwelling

Concentric
Eccentric
Isometric
Concentric
Eccentric
Isometric

Uhl et al.60 (2003)

21

18

19e25

NA

NA

18

Surface &
indwelling

Isometric

Wise et al.61 (2004)

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.

TABLE 2. Rotator Cuff Exercises


Exercise

Muscle(s)
46

Isometric external rotation

Infraspinatus

Side-lying external rotation49

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.

scapula and prevent scapular winging. The included


articles noted that the following periscapular exercises elicited the highest MVIC: prone extension,15,17,32 horizontal abduction (extension) at 908
with full external rotation,29 overhead arm raise at
1258 ,29 inferior glide,24 lawnmower,24 push-up
plus,56 dynamic hug,56 and wall slide.30,61 These
exercises specifically target the serratus anterior and
middle and lower trapezius muscles18 (Table 3).
Review of the 14 periscapular exercise articles
describes how conditioning and strengthening of
the above-mentioned exercises is key to a balanced
shoulder rehabilitation program. According to
Ekstrom et al.,29 the trapezius and serratus anterior
musculature are the most important for restoring
normal rhythm. However, poor serratus anterior
activation may be overpowered by the upper trapezius and cause additional pain in shoulder
impingement patients secondary to the upper trapezius promoting excessive scapular elevation and
anterior tilt.15,17,24,29,53,54,59 Therefore, the focus of
strengthening the serratus anterior muscle appears
imperative if the goal is to decrease impingement
pain.15,17,24,29,53,54,59
Consequently, before prescribing shoulder exercises, consideration must also be given to scapular
muscle balance.15,17,24,29,53,54,59 Specifically, the ratio
of muscle strength between the UT, MT, LT, and
SA muscles must be balanced.15,17,24,29,53,54,59 Cools
et al.17 state, For patients with an imbalance in
the scapular muscles, selective activation of weaker
muscle parts, with minimal activity in the hyperactive muscles, is an important component in the
reduction of the imbalance . lack of activity in

the lower trapezius, middle trapezius, and serratus


anterior frequently is combined with excessive use
of the upper trapezius. Excessive activation of the
upper trapezius with deceased control of the lower
trapezius and serratus anterior has been proposed
as contributing to abnormal scapular motion.
They suggest that selection of specific shoulder exercises due to scapular dyskinesis should not solely
be based on absolute strength values but include
muscle balance ratios based on EMG analysis.17
They also state, The selection of appropriate exercises in the rehabilitation of scapular muscle performance depends on the actual strength of the
muscles but also the relative strength of 1 muscle
in relation to another.17
Moseley et al.48 and Cools et al.17 both demonstrated high EMG activity of the middle trapezius
with prone extension; Cools et al.17 further noted
minimal upper trapezius activity with prone extension and a corresponding low UT/MT ratio. Prone
abduction (extension) with external rotation at 908 29
and the arm raise overhead at 1258 29 both target the
middle and lower trapezius musculature.59
The inferior glide is an isometric exercise that
primarily targets the lower trapezius and serratus
anterior while emphasizing humeral head depression and scapular retraction.18 The isometric low row
also principally targets the lower trapezius and serratus anterior but emphasizes scapular external rotation and posterior tilt.18 Likewise, the lawnmower
recruits the lower trapezius and serratus anterior
through a multijoint movement in which the serratus
anterior works to maintain scapular retraction in an
externally rotated posture.18
OctobereDecember 2011 327

Serratus anterior

Serratus anterior

Dynamic hug56

Wall slide30,61

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DISCUSSION

ER external rotation.

Serratus anterior

Lawnmower24

Isometric low row24

Push-up plus56

Prone horizontal abduction (extension) at 1258 with full ER.


Seated with arm abducted to 908 , wrist neutral position, elbow extended, and fist clenched on a full supportive surface.
Apply pressure in an adduction direction and inferiorly depress the scapula.
Subject stands in front of an immovable surface. The patient places hand on the edge of the surface with the palm facing
posteriorly. Apply pressure to the surface; retract and depress the scapula.
Start with trunk flexed and rotated to the opposite side from the affected arm at the contralateral patella. Rotate trunk
toward affected arm, while extending the hip and trunk to vertical. Affected arm then simultaneously retracts the
scapula with elbow flexed.
Subject prone with hands shoulder width apart and chest near the ground; subject then extends elbows to a standard pushup position, then continue to rise up by protracting the scapula.
Horizontal flexion of humerus at a constant 608 of humeral elevation while hands follow an imaginary arc until maximum
protraction is attained.
Subject stands facing wall with dominant foot at the base of the wall with opposite foot shoulder width and behind
dominant foot. Ulnar portion of arms in contact with smooth wall with shoulder and elbow flexed at 908 ; subject
instructed to slide forearms up and down the wall.
Middle and low trapezius
Low trapezius, serratus
anterior
Low trapezius, serratus
anterior
Low trapezius, serratus
anterior

Prone shoulder extension with elbow in full extension


Prone horizontal abduction at 908 with full ER.
Middle trapezius
Middle trapezius

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)

TABLE 3. Periscapular Exercises

328

The exercises (push-up plus, dynamic hug, and


wall slide) that elicited the greatest amount of
serratus anterior muscle activity were those that
maintained an upwardly rotated and protracted
scapula.56 It is important to note that the highest
level of serratus anterior EMG activity can be
achieved in a range of motion below 908 of humeral
elevation.56 Clinically, this is important with shoulder that presents with impingement and/or scapular winging in which case the standard push-up
plus exercises are optimal, as it yields a low
UT/SA ratio.53,56 The standard push-up plus exercise produces minimal upper trapezius activation
and maximum activation of the serratus anterior
muscle.42

This narrative review synthesizes a group of


evidence-based exercises that focused on stabilizing
the scapulothoracic and scapulohumeral joints while
fostering scapulohumeral rhythm. The EMG data
further provide empirical evidence to suggest a series
of shoulder exercises based on MVIC of individual
and collective rotator cuff muscles.
It is the authors hope that the series of exercises
outlined (Appendix 1) will assist occupational and
physical therapists in selecting a program that will
ensure balance between rotator cuff and periscapular musculature while promoting proper scapulohumeral and scapulothoracic rhythm. Specifically, the
suggested exercises are aimed to promote strength,
balance, and coordination between the principal
scapular rotators, the UT and SA muscles, and the
rotator cuff musculature.32,51,56 Decker et al.56 state,
A fatigued serratus anterior muscle will reduce
scapular rotation and protraction and will allow
the humeral head to translate anteriorly and superiorly, possibly leading to secondary impingement
and rotator cuff tears. According to Ludewig and
Cook,16 For patients with an imbalance of UT to
SA activation, an exercise that demonstrates a low
UT/SA ratio would be an important component of
rehabilitation to allow selective SA strengthening
and reduction of the imbalance. Consequently, the
authors suggest that priority be placed on shoulder
exercises that promote a low UT/SA, UT/LT, and
UT/MT ratios. Some reviewed articles described
several rotator cuff and periscapular exercises that
yielded high EMG results but promoted either postural recruitment or high activation of the upper trapezius; these exercises were not selected as exercises
to be included in Appendix 1. Additionally, the
authors also recommend exercises that produce a
low UT/LT ratio during specific rotator cuff exercises (i.e., side-lying ER and prone horizontal abduction with ER).17

There were two principal limitations to this study.


One, this study reviewed a limited number of articles.
The inclusion criteria set by the researchers prevented
many shoulder exercise EMG articles from being
included. However, these stringent criteria also added
validity and repeatability to the study. Second, EMG
electrode placement can migrate during muscle activity yielding relatively poor reproducibility between
testers leading to divergent data between studies.56 In
addition, results from surface and fine-needle EMG
can be marked depending on the muscle tested.56

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

Isometric External Rotation

Infraspinatus

Rotator Cuff

Seated with arm fully adducted to side, elbow


flexed to 90 degrees, feet flat on floor, and knees
bent to 90 degrees. Patient applies 10e40% of
maximum voluntary isometric contraction
(MVIC) of shoulder ER.

Sidelying External Rotation55

Infraspinatus
Teres Minor

Rotator Cuff

Sidelying with arm fully adducted to side and


internally rotated, with elbow flexed to 90
degrees. Patient then externally rotates the
shoulder up towards the ceiling.

Full Can54

Supraspinatus

Rotator Cuff

Standing-Patient elevates arm to 30 degrees


abduction (scaption) with full glenohumeral
external rotation.

Prone horizontal abduction (extension)


@ 100 degrees with full ER55,62

Supraspinatus

Rotator Cuff

Prone horizontal abduction (extension) @ 100


degrees with full ER. Subject lifts hand toward
the ceiling keeping head/neck neutral.

Zero-position IR61

Subscapularis

Rotator Cuff

Zero rotation of the humerus, arm elevated to 155


degrees (in scapular plane), resistance applied
against internal rotation.

Push-up Plus10

Subscapularis

Rotator Cuff

Prone with hands shoulder-width apart and chest


near the ground; subject then extends elbows to
a standard push-up position, continue to rise up
by protracting the scapula.

Ending Position

OctobereDecember 2011 331

(Continued)

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APPENDIX (Continued )
Exercise

Principle Muscle(s)

Muscle Group

Description

Subscapularis

Rotator Cuff

Prone extension6,11,48

Middle Trapezius

Periscapular

Standing, knees slightly bent, feet shoulder width


apart in split stance, elastic resistance grasped at
shoulder height, elbow slightly flexed and
humerus in neutral position, abducted to 90
degrees; subject horizontally flexs, adducts and
internally rotates humerus until hand at
opposite anterior superior illiac spine.
Prone shoulder extension with elbow in full
extension.

Horizontal Extension with ER @ 90 degrees15

Middle Trapezius
Lower Trapezius

Periscapular

Prone horizontal abduction (extension) @ 90


degrees with full ER. Head/neck in neutral.

Inferior Glide29

Serratus Anterior
Lower Trapezius

Periscapular

Seated with arm abducted to 90 degrees, wrist


neutral position, elbow extended, fist clenched
on a full supportive surface. Apply pressure in
an adduction direction and inferiorly depress
the scapula.

Isometric Low Row29

Serratus Anterior
Lower Trapezius

Periscapular

Stand in front of an immovable surface. The


patient places hand on the edge of the surface
with the palm facing posteriorly. Apply pressure
to the surface; retract and depress the scapula.

Lawnmower29

Serratus Anterior
Lower Trapezius

Periscapular

Start with trunk flexed and rotated to the opposite


side from the affected arm. Rotate trunk toward
affected arm, while extending the hip and trunk
to vertical. Affected arm then simultaneously
retracts the scapula with elbow flexed.

10

Diagonal Exercise

Starting Position

Ending Position

Overhead Arm Raise @ 125 degrees15

Middle Trapezius
Lower Trapezius

Periscapular

Prone horizontal abduction (extension) @


125
degrees with full ER. Head/neck in neutral.

Push-up Plus9

Serratus Anterior
Lower Trapezius

Periscapular

Wall Slide22,71

Serratus Anterior

Periscapular

Dynamic Hug9

Serratus Anterior

Periscapular

Prone with hands shoulder-width apart and


chest
near the ground; subject then extends
elbows to
a standard push-up position, continue to
rise up
by protracting the scapula.
Stands facing wall in staggered stance with
dominant foot at the base of the wall .
Ulnar
portion of arms in contact with smooth
wall with
shoulder and elbow flexed @ 90 degrees;
subject
instructed to slide forearms up and down
the wall.
Horizontal flexion of humerus at a constant
60
degrees of humeral elevation while hands
follow
an imaginary arc until maximum
protraction is
attained.

OctobereDecember 2011 333

JHT Read for Credit


Quiz: Article #204

Record your answers on the Return Answer Form


found on the tear-out coupon at the back of this
issue or to complete online and use a credit card,
go to JHTReadforCredit.com. There is only one
best answer for each question.
#1. Which of the following is not a function of the serratus anterior muscle?
a. scapular external rotation
c. scapular upward rotation
c. scapular and glenohumeral external rotation
d. scapular posterior tipping
#2. The upward rotators of the scapula are
a. serratus anterior and lower trapezius
b. rhomboid major and minor
c. teres major and upper trapezius
d. middle trapezius and rhomboid major
#3. Scapulothoracic dyskinesis is best described as
a. posterior scapular tilt

334

JOURNAL OF HAND THERAPY

b. abnormalities in scapular motion


c. abnormalities in scapular resting position
d. both b & c
#4. The authors recommend shoulder exercises that
promotes a low
a. LT/UT ratio
b. SA/UT ratio
c. UT/SA ratio
d. SA/LT ratio
#5. A fatigued or de-conditioned serratus anterior
muscle will reduce
a. scapular retraction
b. scapular protraction
c. scapular internal rotation
d. scapular downward rotation
When submitting to the HTCC for re-certification,
please batch your JHT RFC certificates in groups
of 3 or more to get full credit.