Physiotherapy Theory and Practice

An International Journal of Physical Therapy

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An 8-week scapular stabilization exercise program

in an elite archer with scapular dyskinesis
presenting joint noise: A case report with one-year
follow-up

Jin-Taek Kim, Suhn-Yeop Kim & Duck-Won Oh

To cite this article: Jin-Taek Kim, Suhn-Yeop Kim & Duck-Won Oh (2019) An 8-week scapular
stabilization exercise program in an elite archer with scapular dyskinesis presenting joint noise:
A case report with one-year follow-up, Physiotherapy Theory and Practice, 35:2, 183-189, DOI:
10.1080/09593985.2018.1442538

To link to this article: https://doi.org/10.1080/09593985.2018.1442538

Published online: 26 Feb 2018.

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PHYSIOTHERAPY THEORY AND PRACTICE
2019, VOL. 35, NO. 2, 183–189
https://doi.org/10.1080/09593985.2018.1442538

CASE REPORT

An 8-week scapular stabilization exercise program in an elite archer with scapular

dyskinesis presenting joint noise: A case report with one-year follow-up
Jin-Taek Kima, Suhn-Yeop Kim b
, and Duck-Won Oh c

a
Korea Archery Association, Songpa-gu, Seoul, Republic of Korea; bDepartment of Physical Therapy, College of Health and Sport Science,
Daejeon University, Dong-gu, Daejeon, Republic of Korea; cDepartment of Physical Therapy, College of Health Science, Cheongju University,
Cheongju, Chungcheongbuk-do, Republic of Korea

ABSTRACT ARTICLE HISTORY

This case report demonstrates the effects of a scapular stabilization exercise program for mana- Received 24 August 2016
ging the clinical symptoms of scapular dyskinesis in an archer presenting joint noise during Accepted 13 July 2017
shoulder movement. A 31-year-old man with a 20-year career in archery who complained of Revised 21 May 2017
scapular dyskinesis and joint noise during shoulder movement was referred for proper manage- KEYWORDS
ment. The player performed the scapular stabilization exercise program, with an emphasis on Archer; scapular dyskinesis;
strengthening scapular stabilizers and neutralization of scapular position, for 40 min, three times scapular stabilization
per week for 8 weeks (a total of 24 sessions). Measurements included the extent of scapular exercise
deviation, strength of scapular stabilizers, emotional burden related to joint noise, and upper limb
disability. These measurements were taken before and after the intervention and during 1-year
follow-up. After the 8-week intervention, scapular position improved by a range of 3.75–12.88%
and muscle strength improved by a range of 8.69–28.60%. Further, emotional burden and upper
limb disability improved by 56.86% and 91.67%, respectively. A 1-year follow-up showed that
these improvements had been favorably maintained. These findings indicate that shoulder
stabilization exercise may be helpful for alleviating scapular and shoulder problems related to
archery performance.

Introduction Improper scapular position increases stress on tissues

surrounding the shoulder joint while drawing a high-
Archers attempt to shoot an arrow at a given target
poundage archery bow. This leads to symptoms such as
with high precision. High accuracy in archery skills
pain and clicking sounds in the shoulder joint that are
requires the balanced and reproducible muscular con-
challenging to an archer’s performance, because these
trol of the forearm and shoulder, as well as strength and
symptoms can impede concentration during targeting
endurance to maintain the correct upper limb posture
(Lin et al., 2010).
and movement pattern during the drawing, aiming, and
To manage scapular and shoulder problems, clini-
releasing phases (Ertan, Soylu, and Korkusuz, 2005).
cians frequently use modalities such as therapeutic
For archers, repeated use of shoulder and scapular
exercise and postural training, depending on the cause
muscles to hold the upper limb position needed to
of impairment and severity of symptoms (Kibler et al.,
aim and target before shooting an arrow is unavoidable
2013). Scapular stabilization is a critical component of
and may be responsible for positional and mechanical
exercise therapy used to optimize scapular alignment
changes in the shoulder girdle. In addition, overuse and
during upper limb movement that allows the direct
sustained contraction of shoulder muscles in the static
control of the scapular position, thereby allowing
position during archery training lead to negative effects
appropriate length–tension relationships of shoulder
on shoulder condition, including labral tearing and
musculature (Kibler et al., 2013). Although a variety
tendinopathy, due to scapular malalignment and
of therapeutic strategies have been developed to man-
impingement syndrome (Delahaye et al., 2005).
age shoulder symptoms, treatment efforts for shoulder
Scapular dyskinesis that is characterized by observa-
problems associated with prolonged and repetitive
ble changes in scapular position and motion patterns
shoulder actions of archers have received little atten-
leads to alterations in performance of the scapular
tion. In addition, an absence of detailed guidelines for
stabilizing muscles (Kibler and McMullen, 2003).

CONTACT Suhn-Yeop Kim kimsy@dju.kr Korea Archery Association, Songpa-gu, Seoul, Republic of Korea.
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/iptp.
© 2018 Taylor & Francis
184 J.-T. KIM ET AL.
the management of problems specific to archers may be
a major contributing factor that makes the early adop-
tion of suitable treatment difficult. Therefore, the pur-
pose of this case report was to illustrate and report the
outcomes of an exercise program for treating shoulder
problems of an elite archer with scapular dyskinesis
presenting joint noise.
Case description
History
A right-handed, 31-year-old, male, world-class archer
with a career of approximately 20 years complained of a
noise from within the shoulder joint while drawing a
bow to shoot at the target. A popping sound in the
right shoulder (drawing arm) was often produced dur-
ing the aiming phase, when after drawing the bow, the
participant was in the holding position. The noise was
audible to others. This symptom had been present for
5 years; however, there was no other complaint except
for slight discomfort while shooting. There was also no
difficulty performing routine daily activities, and the
participant could still enter competitions because the
shoulder pain was not severe. The participant com-
plained of having difficulty concentrating on a target
Figure 1. Computerized tomography scans showing the upward rotation (UR) angle and superior translation (ST) angle at (A) pretest
and (B) posttest on posterior-coronal view, the protraction (PRO) angle at (C) pretest and (D) posttest on superior axes, and the
inferior-angle tipping (IAT) distance at (E) pretest and (F) post-test on inferior axes.
while aiming at it to achieve highest accuracy and the
participant had anxiety because this affected his
performance.
Examination
An orthopedist with a specialty in managing athletes’
shoulder impairments performed diagnostic tests and a
physical examination to determine the source of the
joint noise. Based on an outcome obtained by a roent-
genologist, magnetic resonance imaging was performed
and revealed a posterosuperior labral tear with tendi-
nosis of the supraspinatus, subscapularis, and the long
head of the biceps brachii. The scapular assistance and
scapular retraction tests were positive, and there was
decreased discomfort during shoulder movement, sug-
gesting the possibility of scapular involvement in
shoulder impingement (Kibler and McMullen, 2003).
In addition, an analysis of the scapular position using
three-dimensional wing computed tomography (CT)
summarized the asymmetry, and the scapular align-
ment was noticeable while resting, with the scapula
abducted, anteriorly tilted, protracted, and upwardly
rotated (Figure 1 A, C, and E) (Park et al., 2013). No
specific abnormal signs and symptoms were found in

any other regions, and there was no neurological
impairment.
Clinical impressions
The findings from scapular assistance and retraction
tests suggested that the postural change in the scapula
may be a factor that aggravated the participant’s
shoulder symptoms (Kibler and McMullen, 2003).
This postural change may be associated with intensive
training for an extended time in which the scapula was
placed at an unbalanced position while pulling a bow-
string and aiming at a target. The participant was
referred to a physical therapist with specialized training
in athletic rehabilitation to establish an optimum ther-
apeutic strategy for relieving his main problems.
Measurements
With no assessor blinding, measurements were per-
formed before and after an 8-week intervention, and
during a 1-year follow-up.
Analysis of scapular position
A 16- or 64-slice multi-detector CT (MDCT) scanner
(Light Speed Pro16 or Light Speed VCT; GE
Healthcare, Little Chalfont, Bucks, UK) was used to
obtain 3-dimensional wing CT images for the measure-
ment of the angles (upward rotation [UR], superior
translation [ST], and protraction [PRO]) and inferior-
angle tipping (IAT) distance (Table 1). The scanning
parameters included tube voltage, 120 kV; tube current,
300 mA; slice thickness, 2.5 mm; effective pitch, 0.938
for 16-MDCT and 0.975 for 64-MDCT; and field of
view, 50 cm2. The 3D volume-rendered image was
created on a CT workstation, with a 0.625 or 1.25-
mm reconstruction slice thickness. Average CT dose
index volume ranged from 15.6 to 29.9 mGy, and the
dose-length product ranged from 350 to 750 mGy cm.
An examination was performed with the athlete in the
Table 1. Description of the parameters of the CT scanning.
Parameters Methods
UR angle Angle between the extension of a line from the
acromioclavicular joint to the root of the scapular spine
and the vertebral axis (C7–T7)
ST angle Angle between the line extending from the
acromioclavicular joint to the midpoint of the spinous
process of the C7 vertebra and the vertebral axis (C7–T7)
PRO angle Angle between the line parallel to the vertebral axis (C7–
T7) and the line extending from the centers of the
acromioclavicular joint and the C7 vertebral body
IAT distance Inferior-axial view indicates the distance between the
scapular inferior angle and the rib, vertically
UR: Upward rotation; ST: superior translation; PRO: protraction; IAT: inferior-angle
tipping.
PHYSIOTHERAPY THEORY AND PRACTICE 185
supine position and his arms by his sides. This mea-
surement has been highly reliable in clinical use (inter-
rater reliability: ICC = 0.97, and intra-rater reliability:
ICC = 0.99) and shows concurrent validity with a
method using videotapes that enable observers to cate-
gorize scapular dyskinesis by examining flexion move-
ment in the scapular plane (Park et al., 2013).
Strength
The strength of the scapular stabilizers (upper, middle,
and lower trapezius [UT, MT, and LT, respectively] and
serratus anterior [SA] muscles) on the right side was
measured in the standard manual muscle testing posi-
tion (Michener, Boardman, Pidcoe, and Frith, 2005) by
using a handheld dynamometer (JTech Power Track II,
JTech Medical, Salt Lake City, USA). Strength was
averaged over three trials with a 1-min rest interval.
Intra-rater reliability for strength measurements was
reported by a previous study (ICC = 0.89–0.96)
(Michener, Boardman, Pidcoe, and Frith, 2005).
Emotional burden and disability
Emotional burden was assessed using a fear-avoidance
belief questionnaire (FABQ). Although the FABQ is an
assessment tool used to identify psychological and emo-
tional behaviors associated with back pain (Waddell
et al., 1993), we used the FABQ to assess apprehension
in a history of shoulder joint noise during archery
performance such as drawing, targeting, and shooting,
with a modification of the FABQ by replacing the
expression “low back pain” with “shoulder join noise.”
Shoulder disability was assessed with the sports module
of disabilities of the arm, shoulder, and hand (SM-
DASH). The FABQ (test–retest reliability – physical
activity: ICC = 0.69, and work: ICC = 0.55) (Inrig,
Amey, Borthwick, and Beaton, 2012) and SM-DASH
(test–retest reliability: ICC = 0.91) (Beaton et al., 2001;
Schmitt and Di Fabio, 2004) are reliable and valid for
the upper extremity. In these assessments, a higher
score indicates a greater emotional burden and
shoulder disability.
Intervention
The scapular stabilization exercise program was
developed by modifying an exercise program used in
previous studies (Escamilla, Yamashiro, Paulos, and
Andrews, 2009; Oyama, Myers, Wassinger, and
Lephart, 2010) and consisted of five exercises with
increasing resistance in sequence, emphasizing nor-
malization of the function of scapular stabilizing
muscles and optimization of scapular alignment in
static and dynamic conditions. The detailed
186 J.-T. KIM ET AL.
description for the exercise program is provided in
Appendix 1. This program focuses on recruiting mus-
cular effort to achieve scapular retraction, which con-
tributes to the recovery of scapular position, thereby
enhancing scapular kinematics during shoulder move-
ments (De Mey, Danneels, Cagnie, and Cools, 2012).
Based on the participant’s response and compliance
with the exercise program, the exercise load was
advanced by adding weight force and modifying elas-
tic band tension. Determination of weight force was
based on 20-repetition maximum testing, every
2 weeks. The athlete participated in 24 exercise ses-
sions averaging 40 min each, three times a week, for
8 weeks. During the first 6 weeks of treatment, the
therapeutic focus was on improving postural aware-
ness and muscular function needed for maintaining
the neutral position of the scapula and enhancing
scapular stabilization. In the last 2 weeks, progressive
exercises involved the use of a therapeutic ball to
enable reinforcement of the scapular control in the
functional position. This technique has been clinically
used as an efficient tool to increase exercise load
progressively with safe adaptation of scapular control
in a closed-chain environment. The participant was
instructed to carry out the self-exercise program daily
at home, and an exercise booklet describing scapular
stabilization exercises was provided to facilitate the
self-performance of the program.
Outcomes
Based on the analysis of the scapular position using 3-
dimensional CT, the athlete achieved significant gains
in UR (gain [improvement rate], 16.4° [12.88%]), ST
(3.5° [3.75%]), and PRO (6.8° [6.65%]) angles, and IAT
distance (3.8 mm [8.98%]) after the intervention
(Figure 1B, D, and F). At 1-year follow-up, the scapular
position improved and CT evaluation was no longer
required because a near-normal alignment had been
achieved when distances between the scapulae and
thoracic vertebrae were measured (Sobush et al.,
1996). In addition, after the intervention, the strength
of the UT (2.71 kg [8.69%]), MT (4.19 kg [19.76%]), LT
(6.33 kg [28.60%]), and SA (5.74 kg [17.60%]) had
improved, and the FABQ and SM-DASH scores
decreased by 29 points (56.86%) and 68.75 points
(91.67%), respectively. Moreover, during archery per-
formance, the joint noise was markedly reduced to the
extent that it was no longer audible to others, including
coaching staffs, physical trainers, and teammates. In
addition, the participant reported the smooth use of
the arm during drawing, aiming, and shooting move-
ments. Gains in the strength of each muscle and the
Table 2. Outcomes measured at pretest, posttest, and 1-year
follow-up.
Pretest Posttest 1-year follow-up
Strength (kg)
Upper trapezius 31.18 33.89 35.00
Middle trapezius 21.20 25.39 30.67
Lower trapezius 22.13 28.46 30.33
Serratus anterior 32.61 38.35 43.67
FABQ (score) 51 22 19
SM-DASH (score) 75.00 6.25 6.25
FABQ: Fear-avoidance belief questionnaire; SM-DASH: sports module-dis-
ability of the arm shoulder and hand.
SM-DASH and FABQ scores appeared to be main-
tained at 1-year follow-up (Table 2).
Discussion
Archers must repeatedly use their upper limbs to draw
and shoot a bowstring to ensure that they hit the
appropriate target. Drawing and shooting a bow
involves stress on shoulders; therefore, archers are at
high risk for injury, including inflammation of the
muscles and tendons in the shoulder. However, they
feel a great difficulty in finding an optimal strategy to
avoid possible shoulder problems during competitive
events and field practices.
High precision at the release of a bowstring requires
fine control of scapular movement toward the body’s axis
after anchoring the scapular position at the end of hor-
izontal shoulder extension (Kim and Park, 2009).
Therefore, in the earlier phase of the intervention, we
focused on strengthening of weakened scapular stabilizers
to neutralize the scapular position. In the later part of the
intervention period, the therapy allowed additional
attempts to adapt to a greater exercise load in a closed-
chain mechanism by using a therapeutic ball and sling
suspension system, depending on the increase of muscle
strength and exercise tolerance. During archery, a closed-
chain movement pattern is demonstrated by drawing a
string on a fixed, recurve bow limb (Kibler and
McMullen, 2003); therefore, our program included fac-
tors similar to those in archery performance. In addition,
the repetition and holding time in each exercise reflected
the international standard (within 20 s in each, maximum
15 arrows) for shooting time in archery competition.
To draw and shoot a bowstring, the scapula is
repeatedly placed in forward rotation, leading to a
decrease in the length of the pectoral muscles and
weakness of the interscapular muscles (Kibler et al.,
2013; Ludewig and Reynolds, 2009). Consequently, as
seen in the athlete of this case report, this posture pulls
the scapula out and away from the middle of the back,
resulting in scapular winging. Decreased activity of
interscapular muscles contributes to disparity between

muscular stabilization efforts and temporospatial
demand during loaded events and may disrupt the
control mechanism of upper limb movement. In addi-
tion, the shoulder joint becomes even more unstable
(Ludewig and Reynolds, 2009), contributing to poor
performance of archers during competitions.
Joint noise may be an important factor that impedes
archers’ concentration on a given target while they pre-
pare to shoot an arrow. Although we could not determine
the noise level of the shoulder joint because of the absence
of a reliable and valid tool for its measurement, our athlete
found it distracting. The FABQ at pretest showed a score
of 51, which indicates that the patient’s apprehension level
was elevated (Holden, Davidson, and Tam, 2010). After
the intervention, the FABQ score improved by 29 points
(56.86%), assuring a criteria of the minimal detectable
change (21 points) in the FABQ (Inrig, Amey,
Borthwick, and Beaton, 2012). Specifically, a history of
joint noise (popping, clicking, or catching) has been
described as an important element in the diagnostic accu-
racy for superior labral anterior posterior (SLAP) lesions
(Abrams and Safran, 2010; Michener, Doukas, Murphy,
and Walsworth, 2011). In the present case report, diag-
nostic tests were positive for shoulder impingement and
SLAP lesion, with tendinopathy in some muscles, which
are demonstrated in cases of scapular dyskinesis (Kibler
et al., 2013). Therefore, our findings suggest that
decreased apprehension to joint noise during the aiming
and shooting phases is a possible effect of the positional
correction of the scapula and recovery of the scapular
dyskinesis.
As seen in this case report, scapular position
improved by a range of 3.75–12.88%, reaching normal
UR (106.2°), ST (85.7°), and PRO (95.9°) angles (Park
et al., 2013), and strength of the scapular stabilizers
improved by a range of 8.69–28.60%. Scapular stabilizers
must have sufficient strength to maintain the scapula in
the optimal position during upper limb movements, and
strength influences the function level of the upper limb
and competition power in archery (Kim and Park, 2009).
Increased shoulder strength may be a basic necessity for
improving scapular alignment and for declining the SM-
DASH score that reflects the disability level of the upper
limb during sports movements or daily routine activities
(De Mey, Danneels, Cagnie, and Cools, 2012). After the
intervention, the improved SM-DASH scores met the
criteria for minimum clinically important difference
(10.2 points) (Schmitt and Di Fabio, 2004).
This case report aimed to report treatment outcomes
of a single case; therefore, it is difficult to conclude that
the abovementioned treatment would be successful for
other archers. Moreover, the lack of control and asses-
sor blinding may be an important factor of the limited
PHYSIOTHERAPY THEORY AND PRACTICE 187
generalizability of our results. Rather, the main purpose
of this case report was to demonstrate the use of an
individually designed intervention to alleviate possible
shoulder symptoms in an archer with scapular dyskin-
esis presenting joint noise. Also, it may also be inap-
propriate to evaluate an athlete’s condition using the
SM-DASH score, which can have a ceiling effect in the
assessment of higher level athletes (Hsu et al., 2010).
Our assessment didn’t involve athletic performance;
therefore, our findings cannot be described as better
performance in competitions. Future studies with a
larger sample size will be required.
Conclusions
In archers with scapular dyskinesis, a well-organized
exercise program needs to relieve shoulder symptoms,
including pain and joint noise, by reinforcing neuro-
muscular control of the shoulder girdle during activities
and preventing shoulder injury. This case report
demonstrated that the scapular stabilization exercise
program alleviated shoulder symptoms in an archer
with scapular dyskinesis. In addition, improved symp-
toms may be crucial for improved performance in
archery competitions. This case report provides clini-
cally relevant information for managing shoulder pro-
blems in athletes who repeatedly perform overhead
activities, including archery, because they often com-
plain of various problems related to scapular dyskinesis.
Declaration of interest
The authors report no conflict of interest.
ORCID
Suhn-Yeop Kim http://orcid.org/0000-0002-0558-7125
Duck-Won Oh http://orcid.org/0000-0001-7430-7134
References
Abrams GD, Safran MR 2010 Diagnosis and management of
superior labrum anterior posterior lesions in overhead
athletes. British Journal of Sports Medicine 44: 311–318.
Beaton DE, Katz JN, Fossel AH, Wright JG, Tarasuk V,
Bombardier C 2001 Measuring the whole or the parts?
validity, reliability and responsiveness of the disabilities
of the arm, shoulder, and hand outcome measure in dif-
ferent regions of the upper extremity. Journal of Hand
Therapy 14: 128–146.
De Mey K, Danneels L, Cagnie B, Cools AM 2012 Scapular
muscle rehabilitation exercises in overhead athletes with
impingement symptoms: Effect of a 6-week training pro-
gram on muscle recruitment and functional outcome.
American Journal of Sports Medicine 40: 1906–1915.
188 J.-T. KIM ET AL.
Delahaye H, Tomaszewski A, Diard JB, Olivier V,
Vanvelcenaher J, Dupont L 2005 The shoulder of the
archer: Clinical, video and isokinetic evaluation.
Isokinetics and Exercise Science 13: 81–88.
Ertan H, Soylu AR, Korkusuz F 2005 Quantification the relation-
ship between FITA scores and EMG skill indexes in archery.
Journal of Electromyography and Kinesiology 15: 222–227.
Escamilla RF, Yamashiro K, Paulos L, Andrews JR 2009
Shoulder muscle activity and function in common
shoulder rehabilitation exercises. Sports Medicine 39:
663–685.
Holden J, Davidson M, Tam J 2010 Can the fear-avoidance
beliefs questionnaire predict work status in people with
work-related musculoskeletal disorders? Journal of Back
and Musculoskeletal Rehabilitation 23: 201–208.
Hsu JE, Nacke E, Park MJ, Sennett BJ, Huffman GR 2010 The
disabilities of the arm, shoulder, and hand questionnaire in
intercollegiate athletes: validity limited by ceiling effect.
Journal of Shoulder and Elbow Surgery 19: 349–354.
Inrig T, Amey B, Borthwick C, Beaton D 2012 Validity and
reliability of the Fear-Avoidance Beliefs Questionnaire
(FABQ) in workers with upper extremity injuries. Journal
of Occupational Rehabilitation 22: 59–70.
Kibler WB, Ludewig PM, McClure PW, Michener LA, Bak K,
Sciascia AD 2013 Clinical implications of scapular dyskin-
esis in shoulder injury: The 2013 consensus statement
from the ‘Scapular Summit’. British Journal of Sports
Medicine 47: 877–885.
Kibler WB, McMullen J 2003 Scapular dyskinesis and its
relation to shoulder pain. Journal of the American
Academy of Orthopaedic Surgeons 11: 142–151.
Kim JT, Park SH 2009 Effect of scapular stabilization exercise
on EMG change of shoulder girdle and trunk muscle
during archer`s shooting. Journal of Sport and Leisure
Studies 38: 1003–1010.
Lin JJ, Hung CJ, Yang CC, Chen HY, Chou FC, Lu TW 2010
Activation and tremor of the shoulder muscles to the
demands of an archery task. Journal of Sports Sciences
28: 415–421.
Ludewig PM, Reynolds JF 2009 The association of scapular
kinematics and glenohumeral joint pathologies. Journal of
Orthopaedic and Sports Physical Therapy 39: 90–104.
Michener LA, Boardman ND, Pidcoe PE, Frith AM 2005
Scapular muscle tests in subjects with shoulder pain and
functional loss: Reliability and construct validity. Physical
Therapy 85: 1128–1138.
Michener LA, Doukas WC, Murphy KP, Walsworth MK
2011 Diagnostic accuracy of history and physical examina-
tion of superior labrum anterior- posterior lesions. Journal
of Athletic Training 46: 343–348.
Oyama S, Myers JB, Wassinger CA, Lephart SM 2010
Three-dimensional scapular and clavicular kinematics
and scapular muscle activity during retraction exer-
cises. Journal of Orthopaedic and Sports Physical
Therapy 40: 169–179.
Park JY, Hwang JT, Kim KM, Makkar D, Moon SG, Han KJ
2013 How to assess scapular dyskinesis precisely: 3-dimen-
sional wing computer tomography-A new diagnostic mod-
ality. Journal of Shoulder and Elbow Surgery 22: 1084–
1089.
Schmitt JS, Di Fabio RP 2004 Reliable change and mini-
mum important difference (MID) proportions facilitated
group responsiveness comparisons using individual
threshold criteria. Journal of Clinical Epidemiology 57:
1008–1018.
Sobush DC, Simoneau GG, Dietz KE, Levene JA, Grossman
RE, Smith WB 1996 The Lennie test for measuring scap-
ular position in healthy young adult females: A reliability
and validity study. Journal of Orthopaedic and Sports
Physical Therapy 23: 39–50.
Waddell G, Newton M, Henderson I, Somerville D, Main CJ
1993 A Fear-Avoidance Beliefs Questionnaire (FABQ) and
the role of fear-avoidance beliefs in chronic low back pain
and disability. Pain 52: 157–168.
 PHYSIOTHERAPY THEORY AND PRACTICE 189

Appendix 1. Scapular stabilization exercise program.

1. Scapular retraction
Start position: Elbow fully extended in the prone position. Further, the arms are lifted with the thumb up and the
shoulder at 90° and 120° abduction, respectively
Repetition: Twenty repetitions of 10 s hold for each exercise

2. Push-up with plus

Start position: The hands are placed just below the shoulder in the prone position. Both elbows are extended to
ensure a standard push-up position, and the scapula is protracted to enable higher rising
Repetition: Twenty repetitions of 5 s hold

3. Scapular retraction and depression

Start position: An elastic band is placed around the shoulder on the drawing side in the standing position, and the
ends of the band are anchored using the opposite hand with the elbow extended and shoulder flexed at 120°,
creating a vector of resistance along the opposite direction of the lower trapezius. The tension at the band is
maintained at 60–70% of the maximal level of perceived resistance. The band is then allowed to retract, depressing
and posteriorly tilting the scapula
Repetition: Twenty repetitions of 10 s hold

4. Dipping
Start position: The athlete is made to sit in a chair with arm rests. The rests are firmly grasped and the body is pushed
with an attempt to lift the body about 2.5 cm off the seat. Scapular retraction and elbow extension on the sides are
maintained
Repetition: Twenty repetitions of 10 s hold

5. Forward leaning
Start position: The athlete is made to kneel in front of the therapeutic ball. The ball is positioned to support the
forearms with elbows at 90° flexion. The athlete is made to lean forward with shoulder flexion and the scapula is
protracted as much as possible. This exercise is progressed to sling suspension system use
Repetition: Twenty repetitions of 5 s hold

The chin is kept tucked and trunk is kept straight while performing all exercises. The repetitions and holding time of each exercise can be modified, and a
rest interval can be maintained during the exercises, depending on the athlete’s requirement. The athlete should be instructed to keep breathing pattern
normal through all procedures. Verbal cues and manual guide should be provided, as needed.