Original Research

Electromyographical Assessment of Passive, Active

Assistive, and Active Shoulder Rehabilitation
Exercises
Timothy L. Uhl, PhD, ATC, PT, Tiffany A. Muir, MS, ATC, Laura Lawson, MS, PT

Objective: To determine the electromyographical (EMG) activation levels of shoulder

musculature during early rehabilitation exercises to regain active range of motion.
Design: Descriptive.
Setting: University clinical research laboratory.
Participants: Ten asymptomatic volunteers (age, 25 ⫾ 5 years; height, 171 ⫾ 7 cm;
weight, 78 ⫾ 15 kg).
Intervention: Fine-wire (supraspinatus and infraspinatus) and surface (anterior deltoid,
upper trapezius, lower trapezius, and serratus anterior) electrodes recorded EMG activity
from each muscle during 12 therapeutic exercises completed during a single testing session
in random order.
Main Outcome Measure: EMG root mean squared amplitude normalized to a per-
centage of maximum voluntary contraction (% MVC).
Results: Passive exercises generated the lowest mean EMG activity (⬍10%) for all muscles
studied. The standing active shoulder elevation exercises generated the greatest mean EMG
activity with an upper boundary of 95% CI (40% MVC). Overall the active-assistive
exercises generated a small (⬍10%) increase in muscle activity compared with the passive
exercises for the supraspinatus and infraspinatus muscles, which was not a significant
increase (P ⬎ .05).
Conclusion: This electrophysiological data in normal volunteers suggest that many
exercises used during the early phase of rehabilitation to regain active elevation do not
exceed 20% MVC. Progression from passive to active-assisted can potentially be performed
without significantly increasing muscular activation levels exercises. Upright active exer-
cises demonstrated a consistent and often a statistically significant increase in muscular
activities supporting that these exercises should be prescribed later in a rehabilitation
program.
PM R 2010;2:132-141

INTRODUCTION
T.L.U. Department of Rehabilitation Sciences,
The ultimate goal of shoulder rehabilitation is to return a person to maximal functional Division of Athletic Training, Rm 210C CT,
levels. The first objective in rehabilitation after surgery or injury is often to help the subject Wethington Building, University of Kentucky,
regain full active motion while giving consideration to his or her healing tissues. Healing 900 S. Limestone Street, Lexington, KY
40536-0200. Address correspondence to:
animal tendons are reported to be 25% of their preinjury strength level at 12 weeks [1]. T.L.U.; e-mail: tluhl2@uky.edu
Health-care professionals often instruct patients to progress to active shoulder exercises as Disclosure: nothing to disclose
tolerated between 6 and 12 weeks after injury/surgery without specific knowledge about the T.A.M. Department of Rehabilitation Sciences,
shoulder muscular activation levels of the exercises. The loads applied during rehabilitation Division of Athletic Training, University of Ken-
exercises must be tailored to progress along a continuum so as not to exceed biomechanical tucky, Lexington, KY
Disclosure: nothing to disclose
limits of healing tissues, yet still facilitate the alignment of newly formed collagen fibers in
L.L. Division of Physical Therapy, University of
a functional pattern [2-4].
Kentucky, Lexington, KY
Electromyography (EMG) has been used to investigate various therapeutic exercises that Disclosure: nothing to disclose
maximally activate shoulder musculature, which provides valuable information for chal- Disclosure Key can be found on the Table of
lenging shoulder musculature at greater levels of muscular activation intensity [5-7]. Studies Contents and at www.pmrjournal.org
in which the authors document specific muscular activation levels along a continuum assist Submitted for publication October 8, 2008;
clinicians to develop exercise progressions [8-10]. McCann et al [8] investigated the 3-phase accepted January 4, 2010.

PM&R © 2010 by the American Academy of Physical Medicine and Rehabilitation

1934-1482/10/$36.00 Vol. 2, 132-141, February 2010
132
Printed in U.S.A. DOI: 10.1016/j.pmrj.2010.01.002
PM&R
Neer shoulder rehabilitation program and demonstrated that
a progression from passive to active to resistive exercises
increases muscular activation intensity as measured by EMG.
Recognition of progression is valuable because it allows cli-
nicians to modify programs up or down a level depending on
a patient’s response. Limited EMG information is known
about rehabilitation exercises used in the early phases of
rehabilitation progression when the clinician is balancing the
goal of regaining motion while not overloading the muscula-
ture [8,11].
The Neer exercise program is the one program with
known activation levels, but other programs’ muscular acti-
vation levels are unknown [12,13]. One commonly used
program initiates passive and active-assistive exercises in
supine by the use of the noninvolved extremity to support the
involved extremity to regain motion [13-15]. This support is
reduced by use of a towel, and resistance is gradually in-
creased by elevating the trunk from supine to vertical. This
program [13] emphasized scapular protraction and active
motions rather than isometric and elastic resistance exercises
as in the Neer program [8]. Another approach incorporates
the entire kinetic chain of the body to facilitate arm elevation
and initially places the hand in contact with a support surface
to unload the weight of the arm [12,16-19].
Although these programs are commonly prescribed dur-
ing the early phases of shoulder rehabilitation, it would be
useful to know the activation levels of primary shoulder
elevation muscles to protect healing tissues. Additionally,
knowledge of muscle activation levels during the progres-
sion from passive, active-assistive, to active exercises
would confirm these purported progressions. Therefore,
the purpose of this study was to describe muscular activa-
tion levels by EMG during commonly prescribed shoulder
rehabilitation programs in participants with asymptomatic
shoulders.
METHODS
Participants
Seven healthy women and 3 healthy men (age, 25 ⫾ 5 years;
height, 171 ⫾ 7 cm; weight, 78 ⫾ 15 kg), volunteered to
participate. Subjects were recruited from the local college
community. The first 10 subjects meeting the following
inclusion criteria were enrolled: (1) no history of significant
shoulder injury (fracture, dislocation, surgery) in the domi-
nant arm; (2) full, pain-free, active shoulder range of motion
(ROM) at the time of data collection; and (3) no contraindi-
cation to fine wire placement or completion of basic scapu-
lothoracic ROM. Before participation, each subject read and
signed an approved consent form approved by the authors’
Institutional Review Board.
Vol. 2, Iss. 2, 2010 133
Testing Procedure
By the use of standard procedures, fine-wire electrodes
(length 35 mm; 27 gauge; California Fine Wire, Grover City,
CA) were placed into the supraspinatus and infraspinatus as
the result of their anatomical location and to minimize cross-
talk [20]. Ag-AgCl surface electrodes (Ambu, Medicotest A/S,
Rugmarken 10, DK-2650, Olstykke, Denmark) were placed
on the anterior deltoid, upper trapezius, lower trapezius, and
serratus anterior of the dominant arm [20-23]. Electrode
placements were confirmed by visualization of the EMG
signal during muscle activation, and all leads were secured
with adhesive tape. With the use of standard manual muscle
test positions, each subject was given instructions to main-
tain the test position while a single examiner exerted a
maximal displacing force, also known as a break test [24].
Each subject completed two 5-second isometric contrac-
tions. The maximal root mean squared (RMS) amplitude
from a 500-ms time window represented 100% of the EMG
amplitude for a muscle.
An electrical goniometer (Biometrics, Cwmfelinfach,
Gwent, UK) was attached by adhesive tape on each subject’s
dominant shoulder with one portion aligned with the spine
of the scapula and the other portion placed at the midline of
the humerus. The electrical goniometer data were collected at
500 Hz and was used to track shoulder motion synchro-
nously with the collection of EMG data. This step allowed for
identification of individual trials of exercises during data
reduction.
Subjects completed 8 repetitions of 12 exercises while
EMG activity was recorded simultaneously from 6 shoulder
muscles. The supraspinatus and infraspinatus were studied
because of their frequent involvement in rotator cuff tendon
pathology [25,26] and dynamic stability role during arm
elevation [27,28]. The anterior deltoid and scapular muscles
were chosen because of their integral role as arm elevators
[28], their reported associated involvement in shoulder pa-
thologies [29,30], and their emphasis in shoulder rehabilita-
tion [31-33].
The 12 exercises examined were chosen because they are
commonly referenced in the rehabilitation literature to regain
active elevation; represent a continuum from passive, active-
assistive, to active; and have not been previously investigated
by the use of EMG to determine their amplitudes during
performance [12-14,16,19,34,35]. There are 2 passive (su-
pine passive elevation and forward bow), 4 active-assistive
(wash-cloth press up close [Figure 1], wash-cloth press-up
apart, towel slides, scapular protraction on a ball [Figure 2]),
and 6 active exercises (supine press-up, wedge press-up
[Figure 3], standing press-up, ipsilateral shoulder flexion,
and ipsilateral step-up with and without a ball [Figure 4])
that are described in detail in Table 1 (12,13,16). Each
exercise was described, demonstrated, and practiced by all
subjects for 3 trials before data collection (Table 1). The order
of the exercise was randomized by having each subject draw-
134 Uhl et al EMG ASSESSMENT OF SHOULDER EXERCISES

ing exercise names from an envelop. Once all 12 exercises

were drawn, that created the order of performance for that
subject. This step was repeated for all subjects to minimize
the effects of fatigue and prevent order biasing.

EMG Data Collection and Reduction

EMG signals were collected by the use of the Myopac system
(Run Technologies, Mission Viejo, CA) and Datapac (Run
Technologies) software data acquisition program (Run Tech-
nologies). The EMG signal was collected at 2000 Hz, with a
common mode rejection ration of 90 dB. A beltpack amplifier
was attached to subject during data collection with the in-
dwelling EMG channels gain set at 1000 ␮V and surface EMG
channels were set at 2000 ␮V [20,36]. The belt-pack was
connected to the receiver by a single thin, flexible 2.34-mm
diameter fiber optic cable. The analog data was converted to Figure 2. Scapular protraction on a ball.
digital signal through 16 bit A-D board (Measurement Com-
puting Corporation, Norton, MA). EMG signals were pro-
cessed by use of the following parameters via Datapac: direct
current offset was corrected for all channels by passive de-
meaning, a finite impulse response band pass filter set at 20 to

Figure 1. Wash cloth press-up with hands close. Figure 3. Wedge press-up.
PM&R
Figure 4. Ipsilateral step-up, no ball.
500 Hz for surface channels, and 10 to 1000 Hz for indwell-
ing channels was applied [20,37].
The start and end of an exercise was determined by
deflection of the electric goniometer. The middle 3 trials of
Vol. 2, Iss. 2, 2010 135
the exercise were identified, and the RMS amplitude of each
trial was determined. The RMS amplitude for each exercise
trial was normalized by representing the data as a percentage
of the maximal RMS amplitude determined from the manual
muscle test [38,39]. The middle 3 trials were averaged to
represent the EMG activity for each muscle of each subject
and used for descriptive data results. The normalized signals
were averaged across the 10 subjects. For descriptive pur-
poses EMG activity was categorized as low (⬍20% maximum
voluntary contraction [MVC]), moderate (20% to 50%
MVC), and high (⬎50% MVC) [8,40,41]. Six separate re-
peated-measures analysis of variance tests were performed,
one for each muscle, with one factor of 12 exercise levels
determined if differences exist between exercises with signif-
icance set at P ⱕ .05. Bonferroni post-hoc analysis was used
to determine difference between specific exercises and to
correct for multiple comparisons with significance set at
P ⱕ .05.
RESULTS
The descriptive results for each muscle depicting type of
exercise and 95% confidence intervals (CIs) is presented for
each muscle separately in Tables 2 through 7. The order of
exercises presented in these tables descends from passive to
active-assistive to active exercises, as would be typically pre-
scribed in a clinical setting. The analysis of variance results
identified that the EMG activation levels did not significantly
differ between passive and active-assistive exercises for the 6
muscles studied (Tables 2–7). The lack of difference does not
support the presence of an exercise progression between
passive to active-assistive exercises studied. There were 2
exceptions to this finding; the supine passive ROM exercise
was found to be significantly lower than the wash-cloth
press-up hand apart exercise for the anterior deltoid (Table 4)
and significantly lower than the wash-cloth press-up hands
close exercise for the serratus anterior (Table 7). An exercise
progression was found between at least one active exercise
and a passive and an active-assistive exercise for all muscles.
Bonferroni post-hoc analysis revealed multiple significant
differences (P ⬍ .05), during the performance primarily of
the standing active exercises (ipsilateral step-ups, ipsilateral
flexion, standing press-up) over several of the passive and
active-assistive exercises (Table 2–7).
The infraspinatus demonstrated low EMG activation lev-
els (⬍20% MVC) throughout all exercises with only the
Standing Press-up (14 ⫾ 6% MVC) generating significantly
more activity than any other exercise (P ⬍ .05, Table 3). The
supraspinatus also demonstrated low EMG activation levels
(⬍20% MVC) for the passive and active-assistive exercises.
The standing shoulder active exercises demonstrated an in-
crease in supraspinatus activity to the moderate category
(95% CI, 14%⫺40% MVC) and demonstrated a significantly
greater activation level over several passive and active-assis-
tive exercises (P ⬍ .05, Table 2).
136 Uhl et al EMG ASSESSMENT OF SHOULDER EXERCISES

Table 1. Exercise description is listed below in order from passive, active assistive, to active exercise in order to facilitate active
elevation

Exercise Type Exercise Name Description

Passive Supine elevation with opposite The subject lies supine with fingers interlocked, with the nonaffected upper
hand (supine passive range extremity aiding the affected extremity into elevation.
of motion)
Passive Forward bow Subject places hand of affected upper extremity on a table. The subject
then steps backward away from the stationary hand while simultaneously
bending at his or her waist, which places the subject into a forward bow
position
Active-assistive Washcloth (WC) press-up The subject lies supine and mimics a chest press-up holding onto a WC
hands close with hands placed close together.
Active-assistive Towel slide The subject stands astride next to a table at waist level with his or her
hand on a towel. The subject slides the towel on the table top away from
his or her body at a 45° from the frontal plane (also known as the
scapular plane). The motion is initiated by shifting their weight from their
back to front foot.
Active-assistive Scapular protraction on ball The subject stands astride next to a table at waist level with his or her
hand on a ball at chest level. The subject slides his or her hand over the
ball allowing the ball to roll away from their body at a 45° from the
frontal plane (also known as the scapular plane). The motion is initiated
by shifting their weight from their back to front foot and the subject is
instructed to protract their scapula at the end of the exercise.
Active-assistive WC press-up hands farther The subject lies supine and mimics a chest press-up holding onto a WC
apart with hands placed farther apart.
Active Supine press-up The subject lies supine, using the affected upper extremity, an aerosol can
is pushed from the subject’s side up towards the ceiling with the scapular
being protracted at the end of the exercise.
Active Wedge press-up The subject lies supine, elevated on a 45° wedge, using the affected
upper extremity, an aerosol can is pushed from the subject’s side up
towards the ceiling with the scapular being protracted at the end of the
exercise.
Active Ipsilateral (Ips) step-up with The subject stands astride with the Ips foot of the affected arm on a
ball standard - inch step and the other on the floor, while a light plastic ball is
held in both hands. The subject shifts his or her weight forward and rises
up onto step as both arms are elevated overhead. The unaffected upper
extremity assists the affected upper extremity through the use of the ball
during this exercise.
Active Ips step-up, no ball Same as above, without the use of a ball.
Active Ips shoulder flexion The subject stands astride with the Ips foot of the affected arm in front.
The subject shifts his or her weight forward and elevates both arms
overhead. The motion should be rhythmic with the lower extremity
preceding the upper extremity.
Active Standing press-up The subject is standing, using the affected upper extremity, an aerosol can
is pushed overhead toward the ceiling from a bent elbow resting
position, with the scapular being protracted at the end of the exercise.

The upper and lower trapezius muscles activity were
found to have similar progression patterns. In both muscles
activity rarely exceeded 10% and never exceeded 20% MVC
when exercises were performed with support or performed
actively in supine position. When exercises were progressed
to a vertical trunk position and arm elevation was unsup-
ported, there was a significant increase in the activation levels
for both muscles over all passive and most of the active-
assistive exercises (P ⬍ .05, Tables 5 and 6).
The anterior deltoid and serratus anterior were the only 2
muscles to demonstrate somewhat of a progression between
and within exercise types (Table 4 and 7). These 2 muscles
produced significantly greater EMG activity between the
active-assistive WC press-up exercises over the passive su-
pine passive ROM exercise (P ⬍ .05, Tables 4 and 7). Within
the active exercises the anterior deltoid demonstrated ap-
proximately 10% to 20% more EMG activity with standing
shoulder elevation exercises over the supine press-up (P ⬍
.05, Table 4). A significant increase from wedge press-up
(17 ⫾ 8% MVC) to standing press-up (29 ⫾ 13% MVC) was
observed similarly for the serratus anterior (P ⬍ .05, Table 7).
DISCUSSION
The goal of the study was to describe EMG activation levels of
exercises commonly prescribed to regain active elevation that
PM&R Vol. 2, Iss. 2, 2010 137

Table 2. Descriptive statistics for supraspinatus EMG muscle activity level represented as percentage of maximal voluntary
contraction (% MVC) and associated 95% confidence intervals (95% CI)

Standard Lower Boundary Upper Boundary

Type of Mean Deviation 95% CI 95% CI Post-Hoc
Exercise Description Exercise (% MVC) (% MVC) (% MVC) (% MVC) P Value
1 Supine passive ROM Passive 1 6 ⫺2 5
2 Forward bow Passive 5 6 1 8
3 WC press-up, hands close A-A 3 7 ⫺1 8
4 Towel slide A-A 7 12 0 15
5 Scapular protraction on ball A-A 5 9 ⫺1 10
6 WC press-up, hands apart A-A 4 7 ⫺1 9
7 Supine press-up Active 4 8 ⫺1 9
8 Wedge press-up Active 8 11 1 15
9 Ips step-up with ball Active 21 16 12 31 1, 4, 5
10 Ips step-up, no ball Active 22 20 10 35
11 Ips shoulder flexion Active 18 15 9 28 1, 4, 5, 7
12 Standing press-up Active 29 18 18 40 1, 2, 3, 5, 6, 7

A-A ⫽ active-assistive exercise; Ips ⫽ ipsilateral; ROM ⫽ range of motion; WC ⫽ wash cloth.
Bonferonni post-hoc (Post-hoc) analysis revealed multiple significant differences between exercises (P ⱕ .05). Exercises that are significantly less than a
particular exercise are identified by their exercise number (ie, exercise 1, supine passive ROM, generates significantly less electromyographic activity than exercise
9, Ips step-up with ball). When no significant differences exist between exercises, no number is presented.

had not been previously studied. Most of the exercises dem-
onstrate low muscle activity (⬍20% MVC) and only a few
exercises for particular muscles have activation in the mod-
erate category (20-50% MVC), whereas none reached a high
level of activity (⬎50% MVC) [8]. These findings provide
electrophysiological documentation to support Matsen et al’s
[14,34,35], Jackins’s [13], and Kibler et al’s [12,19] sugges-
tions to use these exercises early in rehabilitation. The find-
ings from this study corroborate the recommendations of
many health-care professionals to use exercises that require
less than 20% MVC in the acute postinjury or postoperative
period [7,8,11,42].
Passive exercises are important to regain shoulder motion
after an injury. The forward bow exercise has been suggested
to be a passive exercise but has never been previously stud-
ied. The forward bow was found to not be significantly
different from supine passive ROM for any muscle studied.
This study’s findings support the previous suggestions by
Matsen et al [43] that indeed the forward bow exercise is
passive on the basis of EMG results [13,37]. Passive elevation
performed by a therapist has been previously studied [11]
and revealed EMG activity of supraspinatus (4 ⫾ 2%) and
infraspinatus (3 ⫾ 1%) ,which is comparable with the supine
passive ROM exercise in this study, which yielded (1 ⫾ 6%)
and (4 ⫾ 4%) for each muscle, respectively. Dockery et al
[11] also reported EMG activity for the anterior deltoid (8 ⫾
4%) and trapezius (8 ⫾ 3%), which is slightly greater than
the authors’ findings of (3 ⫾ 1%) and (0 ⫾ 3%), respectively.

Table 3. Descriptive statistics for infraspinatus EMG muscle activity level represented as percentage of maximal voluntary
contraction (% MVC) and associated 95% confidence intervals (95% CI)

Standard Lower Boundary Upper Boundary

Type of Mean Deviation 95% CI 95% CI Post-Hoc
Exercise Description Exercise (% MVC) (% MVC) (% MVC) (% MVC) P Value
1 Supine passive ROM Passive 4 4 2 7
2 Forward bow Passive 2 2 0 3
3 WC press-up, hands close A-A 7 5 4 10
4 Towel slide A-A 4 6 0 8
5 Scapular protraction on ball A-A 4 5 1 7
6 WC press-up, hands apart A-A 11 14 2 19
7 Supine press-up Active 9 5 6 13
8 Wedge press-up Active 9 7 5 13
9 Ips step-up with ball Active 18 19 6 29
10 Ips step-up, no ball Active 13 10 7 19
11 Ips shoulder flexion Active 13 11 6 19
12 Standing press-up Active 14 6 10 18 2, 5

A-A ⫽ active-assistive exercise; Ips ⫽ ipsilateral; ROM ⫽ range of motion; WC ⫽ wash cloth.
Bonferonni post-hoc (Post-hoc) analysis revealed 2 significant differences between exercises (P ⱕ .05). Exercises that are significantly less than a particular
exercise are identified by their exercise number (ie, exercise 2, forward bow generated significantly less electromyographic activity than exercise 12, standing
Press-up). When no significant differences exist between exercises, no number is presented.
138 Uhl et al EMG ASSESSMENT OF SHOULDER EXERCISES

Table 4. Descriptive statistics for anterior deltoid EMG muscle activity level represented as percentage of maximal voluntary
contraction (% MVC) and associated 95% confidence intervals (95% CI)

Standard Lower Boundary Upper Boundary

Type of Mean Deviation 95% CI 95% CI Post-Hoc
Exercise Description Exercise (% MVC) (% MVC) (% MVC) (% MVC) P Value
1 Supine passive ROM Passive 3 1 2 3
2 Forward bow Passive 2 1 1 3
3 WC press-up, hands close A-A 7 3 6 9
4 Towel slide A-A 7 4 5 10
5 Scapular protraction on ball A-A 7 4 5 10
6 WC press-up, hands apart A-A 7 3 5 9 1
7 Supine press-up Active 11 4 8 14 1–3
8 Wedge press-up Active 20 9 15 26 1–3, 5, 6
9 Ips step-up with ball Active 25 10 19 32 1–7
10 Ips step-up, no ball Active 22 7 17 26 1–7
11 Ips shoulder flexion Active 24 10 17 30 1–6
12 Standing press-up Active 31 11 24 37 1–7

A-A ⫽ active-assistive exercise; Ips ⫽ ipsilateral; ROM ⫽ range of motion; WC ⫽ wash cloth.
Bonferonni post-hoc (Post-hoc) analysis revealed multiple significant differences between exercises (P ⱕ .05). Exercises that are significantly less than a
particular exercise are identified by their exercise number (ie, exercise 1, supine passive ROM generated significantly less electromyographic activity than exercise
6, WC press-up, hands apart). When no significant differences exist between exercises, no number is presented.

The relative similarity of values and relative low amounts
indicate these exercises approach the closest approximation
of passive exercise that can be prescribed. The forward bow
provides an alternative approach of performing a passive
exercise by keeping the hand still and moving the individual’s
body about the upper extremity for the clinician to use if
lying supine is not well tolerated or painful to a patient.
A clinician would typically progress a patient’s exercises
from passive to active-assistive exercises and would expect an
associated increase in muscular activation levels. Previous
authors [8,11] have observed significant increases in shoul-
der muscle activity when progressing to active-assistive exer-
cise such as pulley or stick assisted elevation exercises. The
percentage increase in the supraspinatus and anterior deltoid
activity ranged from 10% to 30% [8,11]. This amount of
progression may be too large for some individuals. Alterna-
tive active-assistive exercises examined in this study, such as
the “washcloth press-ups” and “towel slides,” were found to
have no significant increase in rotator cuff muscle activation
levels from the passive exercises.
This lack of difference and overlapping CIs observed
indicates muscular activity minimally changes between these
types of exercises. Active-assistive exercises generally are
considered to be more under voluntary control of the pri-
mary movers with some level of support from and external
source, either manually or mechanically [44]. The relatively
small increase in muscular activity observed is likely attrib-
utable to the fact that weight of the arm was supported by a

Table 5. Descriptive statistics for upper trapezius EMG muscle activity level represented as percentage of maximal voluntary
contraction (% MVC) and associated 95% confidence intervals (95% CI)

Standard Lower Boundary Upper Boundary

Type of Mean Deviation 95% CI 95% CI Post-Hoc
Exercise Description Exercise (% MVC) (% MVC) (% MVC) (% MVC) P Value
1 Supine passive ROM Passive 0 2 ⫺1 2
2 Forward bow Passive 2 3 0 4
3 WC press-up, hands close A-A 1 2 0 2
4 Towel slide A-A 4 3 2 6
5 Scapular protraction on ball A-A 5 3 3 7
6 WC press-up, hands apart A-A 1 2 ⫺1 2
7 Supine press-up Active 1 3 ⫺1 3
8 Wedge press-up Active 11 11 5 18
9 Ips step-up with ball Active 24 8 18 29 1–7
10 Ips step-up, no ball Active 21 8 16 26 1–7
11 Ips shoulder flexion Active 20 9 14 25 1–7
12 Standing press-up Active 24 8 19 30 1–8

A-A ⫽ active-assistive exercise; Ips ⫽ ipsilateral; ROM ⫽ range of motion; WC ⫽ wash cloth.
Bonferonni post-hoc (Post-hoc) analysis revealed multiple significant differences between exercises (P ⱕ .05). Exercises that are significantly less than a
particular exercise are identified by their exercise number (ie, exercise 1, supine passive ROM generated significantly less electromyographic activity than exercise
9, Ipsl step-up with ball). When no significant differences exist between exercises, no number is presented.
PM&R Vol. 2, Iss. 2, 2010 139

Table 6. Descriptive statistics for lower trapezius EMG muscle activity level represented as percentage of maximal voluntary
contraction (% MVC) and associated 95% confidence intervals (95% CI)

Standard Lower Boundary Upper Boundary

Type of Mean Deviation 95% CI 95% CI Post-Hoc
Exercise Description Exercise (% MVC) (% MVC) (% MVC) (% MVC) P Value
1 Supine passive ROM Passive 2 2 0 3
2 Forward bow Passive 2 2 1 4
3 WC press-up, hands close A-A 1 1 0 1
4 Towel slide A-A 3 5 0 7
5 Scapular protraction on ball A-A 3 4 1 5
6 WC press-up, hands apart A-A 1 2 0 2
7 Supine press-up Active 1 1 0 2
8 Wedge press-up Active 2 1 1 2
9 Ips step-up with ball Active 13 6 9 17 2, 3, 6–8
10 Ips step-up, no ball Active 14 6 10 17 1, 2, 3, 5–8
11 Ips shoulder flexion Active 14 7 10 18 1–8
12 Standing press-up Active 9 5 6 13 4, 8

A-A ⫽ active-assistive exercise; Ips ⫽ ipsilateral; ROM ⫽ range of motion; WC ⫽ wash cloth.
Bonferonni post-hoc (Post-hoc) analysis revealed multiple significant differences between exercises (P ⱕ .05). Exercises that are significantly less than a
particular exercise are identified by their exercise number (ie, exercise 2, forward bow, generated significantly less electromyographic activity than exercise 9, Ips
step-up with ball). When no significant differences exist between exercises, no number is presented.

surface during the “towel slides” and “scapular protraction on
ball” exercise, thereby decreasing the external load which will
reduced EMG activity [17,45]. Additionally, the external
load acting on the glenohumeral joint decreases during su-
pine washcloth pressing exercises as the upper extremity
moment arm shortens from 0 to 90° when the subject is
supine versus lengthening when in standing [46,47]. This
pressing motion was found to increase activity of the anterior
deltoid and serratus anterior in 2 instances, but overall these
active-assistive exercises did not generate the increase in
muscle activation that others have reported [8,11]. This
finding indicates further research should investigate differ-
ences between the various active-assistive exercises that are
prescribed to determine whether a specific order should be
prescribed.
Upright standing active exercises (standing press-up, ip-
silateral shoulder flexion, ipsilateral step-up with and with-
out a ball) generated the most consistent increase in EMG
activity levels across all muscles. The 10% to 20% increase for
the supraspinatus, anterior deltoid, and upper trapezius is
consistent with previous studies [8] and represents both statis-
tically and categorically a progression when active exercises are
performed in standing [8,40,41]. The increasing EMG activity in
all musculature is best explained by the concept of gradually
lengthening the lever arm to increase the load on shoulder
musculature [13]. It is a logical biomechanical principle that

Table 7. Descriptive statistics for serratus anterior EMG muscle activity level represented as percentage of maximal voluntary
contraction (% MVC) and associated 95% confidence intervals (95% CI)

Standard Lower Boundary Upper Boundary

Type of Mean Deviation 95% CI 95% CI Post-Hoc
Exercise Description Exercise (% MVC) (% MVC) (% MVC) (% MVC) P Value
1 Supine passive ROM Passive 2 2 1 3
2 Forward bow Passive 5 4 3 8
3 WC press-up, hands close A-A 11 6 8 15 1
4 Towel slide A-A 6 3 4 8
5 Scapular protraction on ball A-A 11 8 7 16
6 WC press-up, hands apart A-A 13 11 7 20
7 Supine press-up Active 17 8 12 22 1, 2
8 Wedge press-up Active 17 8 12 22 1, 2
9 Ips step-up with ball Active 18 6 15 22 1, 2, 4
10 Ips step-up, no ball Active 15 5 12 18 1, 2, 4
11 Ips shoulder flexion Active 16 8 11 21 1, 2
12 Standing press-up Active 29 13 21 38 1–4, 8

A-A ⫽ active-assistive exercise; Ips ⫽ ipsilateral; ROM ⫽ range of motion; WC ⫽ wash cloth.
Bonferonni post-hoc (Post-hoc) analysis revealed multiple significant differences between exercises (P ⱕ .05). Exercises that are significantly less than a
particular exercise are identified by their exercise number (ie, exercise 1, supine passive ROM generated significantly less electromyographic activity than exercise
7, supine press-up). When no significant differences exist between exercises, no number is presented.
140 Uhl et al
longer lever arms increase loads to the shoulder joint and con-
currently increase muscular activity [46-48].
This is well illustrated in the increasing activity of the
anterior deltoid from the active “supine press-up” (11 ⫾ 4%)
to the “wedge press-up” (20 ⫾ 9%) to the “standing press-up”
(31 ⫾ 11%). In this progression, the resistance remains
constant only the trunk position is incrementally more verti-
cal, thereby increasing the moment arm acting on shoulder
musculature which requires more anterior deltoid activity to
overcome the external torque. The use of the intermediate
“wedge press-up” exercise, however, does not create a signif-
icant increase in EMG activity from the “supine press-up,”
which allows for a gradual transition before progressing to
the “standing press-up,” which generated the most EMG
activity for all musculature except for the lower trapezius and
infraspinatus.
The infraspinatus and lower trapezius were the least active
of the muscles studied and may behave differently as the
result of their primary roles. The infraspinatus is an impor-
tant stabilizer of the humerus [49-51] and demonstrated
more of a constant activation with all exercises, likely as the
result of its stabilizing force-couple role during elevation
[28]. It has been documented that EMG activity of the in-
fraspinatus increases with more external rotation and abduc-
tion motion [49,52]. The motions performed in this study
were primarily in flexion, not external rotation, and therefore
the infraspinatus maintained a relative constant level of ac-
tivity. The lower trapezius functions within a force couple
with the serratus anterior and upper trapezius to rotate
scapula upward during active elevation [28,53]. The lower
trapezius has broad attachment along the thoracic spinous
processes [24,54] and has been found to contribute to main-
tain an erect trunk during gait [55]. The greater activity
during ipsilateral shoulder flexion exercises is most likely
attributed to the engagement of the kinetic chain as these
exercises incorporates trunk extension with shoulder eleva-
tion [16]. Smith et al [41] found a similar nonsignificant
increase of 10% when evaluating the incorporation of a step
during exercises in healthy patients. These findings seem to
suggest that incorporation of the kinetic chain step motion
has minimal but potentially facilitating effect on the lower
trapezius musculature.
Study Limitations
There were 3 primary limitations with this study. First, this
study was limited by a small sample of subjects. Second, no
injured population was used in the data collection in which
to make a comparison. Therefore, extrapolating these results
to an injured population should be undertaken with caution.
Finally, each subject performed the exercises at a self-selected
speed. Future studies should include an injured population
for purpose of comparison and findings of notable differ-
ences, as well as using a metronome to control the rate of
movement.
EMG ASSESSMENT OF SHOULDER EXERCISES
CONCLUSIONS
This study describes that many exercises used during the
early-phase rehabilitation to regain active elevation do not
exceed 20% MVC. On the basis of electrophysiological data
in normal volunteers, these findings identify that the forward
bow exercise can be considered to require no more rotator
cuff or deltoid activity than passive supine elevation. The
active-assistive exercises studied did not generally increase
muscular demands from the passive exercises, suggesting
that different levels of active-assistive exercises may exist
along a continuum. The upright active exercises demon-
strated a consistent and often a statistically significant in-
crease in muscular activities supporting that these exercises
require more muscular activation to perform and should be
prescribed later in a progressive program. The primary fac-
tors clinicians should consider in prescribing exercises to
minimize muscular activation levels are position of the body
in relation to gravitational effects on the arm, the amount of
support provided to the arm, and the length of the moment
arm generated during the exercise.
ACKNOWLEDGMENTS
The authors would like to thank Katie Klare for her help with
data collection and initial statistical analysis.
REFERENCES
1. Uhthoff HK, Sarkar K. Classification and definition of tendinopathies.
Clin Sports Med 1991;10:707-720.
2. Woo SL, Gomez MA, Sites TJ, Newton PO, Orlando CA, Akeson WH.
The biomechanical and morphological changes in the medial collateral
ligament of the rabbit after immobilization and remobilization. J Bone
Joint Surg Am 1987;69(8):1200-1211.
3. Noyes FR. Functional properties of knee ligaments and alterations
induced by immobilization: A correlative biomechanical and histolog-
ical study in primates. Clin Orthop Rel Res 1977;123:210-243.
4. Schollmeier G, Uhthoff HK, Sarkar K, Fukuhara K. Effects of immobi-
lization on the capsule of the canine glenohumeral joint. A structural
functional study. Clin Orthop Rel Res 1994;304:37-42.
5. Blackburn TA, McLeod WD, White B, Wofford L. EMG analysis of
posterior rotator cuff exercises. J Athletic Training 1990;25:40-45.
6. Kronberg M, Gunnar N, Brostrom L. Muscle activity and coordination
in the normal shoulder, an electromyographic study. Clin Orthop Rel
Res 1990;257:76-85.
7. Townsend H, Jobe FW, Pink M, Perry J. Electromyographic analysis of
the glenohumeral muscles during a baseball rehabilitation program.
Am J Sports Med 1991;19:264-272.
8. McCann PD, Wootten ME, Kadaba MP, Bigliani LU. A kinematic and
electromyographic study of shoulder rehabilitation exercises. Clin Or-
thop Rel Res 1993;288:179-188.
9. Decker MJ, Hintermeister RA, Faber KJ, Hawkins RJ. Serratus anterior
muscle activity during selected rehabilitation exercises. Am J Sports
Med 1999;27(6):784-791.
10. Decker MJ, Tokish JM, Ellis HB, Torry MR, Hawkins RJ. Subscapularis
muscle activity during selected rehabilitation exercises. Am J Sports
Med 2003;31(1):126-134.
11. Dockery ML, Wright TW, LaStayo PC. Electromyography of the shoul-
der: An analysis of passive modes of exercise. Orthopaedics 1998;
21(11):1181-1184.
PM&R
12. Kibler WB, McMullen J, Uhl T. Shoulder rehabilitation strategies,
guidelines, and practice. Orthop Clin North Am 2001;32(3):527-538.
13. Jackins S. Postoperative shoulder rehabilitation. Phys Med Rehabil Clin
North Am 2004;15(3):643-682.
14. Matsen FA, Lippitt SB, Sidles JA, Harryman DT. Practical Evaluation
and Management of the Shoulder. Philadelphia: WB Saunders; 1994.
15. Goldberg BA, Nowinski RJ, Matsen FA 3rd. Outcome of nonoperative
management of full-thickness rotator cuff tears. Clin Orthop Relat Res
2001;Jan(382):99-107.
16. McMullen J, Uhl TL. A kinetic chain approach for shoulder rehabilita-
tion. J Athletic Training 2000;35(3):329-337.
17. Wise MB, Uhl TL, Mattacola CG, Nitz AJ, Kibler WB. The effect of limb
support on muscle activation during shoulder exercises. J Shoulder
Elbow Surg 2004;13(6):614-620.
18. Rubin BD, Kibler WB. Fundamental principles of shoulder rehabilita-
tion: conservative to postoperative management. Arthroscopy 2002;
18(9 suppl 2):29-39.
19. Kibler WB. Shoulder rehabilitation: principles and practice. Med Sci
Sports Exerc 1998;30(4):S40-S50.
20. Basmajian JV, De Luca CJ, Butler JP. Apparatus, Detection, and Record-
ing Techniques. Muscle Alive, Their Functions Revealed by Electro-
myography. Baltimore, MD: Williams & Wilkins; 1985, 19-64.
21. Arwert HJ, de Groot J, Van Woensel WWLBM, Rozing PM. Electromyo-
graphy of shoulder muscles in relation to force direction. J Shoulder
Elbow Surg 1997;6(4):360-370.
22. Zipp P. Recommendations for the standardization of lead positions in
surface electromyography. Eur J Appl Physiol Occup Physiol 1982;50:
41-54.
23. Perotto AO, Charles CT. Anatomical Guide for the Electromyographer.
Springfield; 1994.
24. Kendall FP, McCreary EK, Provance PG, Butler JP. Upper extremity and
shoulder girdle strength test. In: Muscle Testing and Function. Balti-
more, MD: Williams & Wilkins; 1993, 235-298.
25. Cofield RH, Parvizi J, Hoffmeyer PJ, Lanzer WL, Ilstrup DM, Rowland
CM. Surgical repair of chronic rotator cuff tears. A prospective long-
term study. J Bone Joint Surg Am 2001;83-A(1):71-77.
26. Tempelhof S, Rupp S, Seil R. Age-related prevalence of rotator cuff tears in
asymptomatic shoulders. J Shoulder Elbow Surg 1999;8(4):296-299.
27. Yanagawa T, Goodwin CJ, Shelburne KB, Giphart JE, Torry MR, Pandy
MG. Contributions of the individual muscles of the shoulder to gleno-
humeral joint stability during abduction. J Biomech Eng 2008;130(2):
021024.
28. Inman VT, Saunders M, Abbot LC. Observations of the function of the
shoulder joint. J Bone Joint Surg Am 1944;26(1):1-30.
29. Scovazzo ML, Browne A, Pink M, Jobe FW, Kerrigan J. The painful
shoulder during freestyle swimming, an electromyographic cinemato-
graphic analysis of twelve muscles. Am J Sports Med 1991;19(6):577-582.
30. Ludewig PM, Cook TM. Alterations in shoulder kinematics and asso-
ciated muscle activity in people with symptoms of shoulder impinge-
ment. Phys Ther 2000;80(3):276-291.
31. Ludewig PM, Hoff MS, Osowski EE, Meschke SA, Rupp S. Relative
balance of serratus anterior and upper trapezius muscle activity during
push-up exercises. American J Sports Med 2004;32(2):484-493.
32. Wilk KE, Meister K, Andrews JR. Current concepts in the rehabilitation of
the overhead throwing athlete. Am J Sports Med 2002;30(1):136-151.
33. Wilk KE, Reinold MM, Dugas JR, Arrigo CA, Moser MW, Andrews JR.
Current concepts in the recognition and treatment of superior labral
(SLAP) lesions. J Orthop Sports Phys Ther 2005;35(5):273-291.
34. Matsen FA, Harryman DT, Sidles JA. Mechanisms of glenohumeral
instability. Clin Sports Med 1991;10(4):783-788.
35. Harryman DT 2nd, Hettrich CM, Smith KL, Campbell B, Sidles JA,
Matsen FA 3rd. A prospective multipractice investigation of patients
Vol. 2, Iss. 2, 2010 141
with full-thickness rotator cuff tears: The importance of comorbidities,
practice, and other covariables on self-assessed shoulder function and
health status. J Bone Joint Surg Am 2003;85-A(4):690-696.
36. Hermens HJ, Freriks B, Disselhorst-Klug C, Rau G. Development of
recommendations for SEMG sensors and sensor placement procedures.
J Electromyogr Kinesiol 2000;10:361-374.
37. Uhl TL, Carver TJ, Mattacola CG, Mair SD, Nitz AJ. Shoulder muscu-
lature activation during upper extremity weight-bearing exercise. J Or-
thop Sports Phys Ther 2003;33(3):109-117.
38. Kendall FP, McCreary EK, Provance PG, Butler JP. Muscles Testing and
Function. Baltimore, MD: Williams and Wilkins; 1993.
39. Kelly BT, Kadrmas WR, Kirkendall DT, Speer K. Optimal normaliza-
tion tests for shoulder muscle activation: an electromyographic study.
J Orthop Res 1996;14(4):647-653.
40. Smith J, Kotajarvi BR, Padgett DJ, Eischen JJ. Effect of scapular protrac-
tion and retraction on isometric shoulder elevation strength. Arch Phys
Med Rehabil 2002;83:367-370.
41. Smith J, Dahm DL, Kotajarvi BR, et al. Electromyographic activity in the
immobilized shoulder girdle musculature during ipsilateral kinetic
chain exercises. Arch Phys Med Rehabil 2007;88(11):1377-1383.
42. Hintermeister RA, Lange GW, Schultheis JM, Bey MJ, Hawkins RJ.
Electromyographic activity and applied load during shoulder rehabili-
tation exercises using elastic resistance. Am J Sports Med 1998;26(2):
210-220.
43. Matsen FA. Shoulder motion. In: Matsen FA, Lippit SB, Sidles JA,
Harryman DT, eds. Practical Evaluation and Management of the Shoul-
der. Philadelphia: WB Saunders; 1994, 19-58.
44. Kisner C, Colby LA, Kisner C, Colby LA. Resistance exercise. In:
Therapeutic Exercise Foundations and Techniques. Philadelphia: F.A.
Davis Company; 1996, 56-109.
45. Kelly BT, Roskin LA, Kirkendall DT, Speer KP. Shoulder muscle
activation during aquatic and dry land exercises in nonimpaired sub-
jects. J Orthop Sports Phys Ther 2000;30(4):204-210.
46. Otis JC, Jiang CC, Wickiewicz TL, Peterson MG, Warren RF, Santner TJ.
Changes in the moment arms of the rotator cuff and deltoid muscles with
abduction and rotation. J Bone Joint Surg Am 1994;76(5):667-676.
47. Dillman CJ, Murray TA, Hintermeister RA. Biomechanical differences
of open and closed chain exercises with respect to the shoulder. J Sport
Rehabil 1994;3:228-238.
48. Poppen NK, Walker PS. Forces at the glenohumeral joint. Clin Orthop
Rel Res 1978;Sep(135):165-170.
49. Bitter NL, Clisby EF, Jones MA, Magarey ME, Jaberzadeh S, Sandow MJ.
Relative contributions of infraspinatus and deltoid during external
rotation in healthy shoulders. J Shoulder Elbow Surg 2007;
16(5):563-568.
50. Lippitt SB, Matsen FA. Mechanism of glenohumeral joint stability. Clin
Orthop Rel Res 1993;291:20-28.
51. Halder AM, Itoi E, An K. Conservative management of shoulder injuries
anatomy and biomechanics of the shoulder. Orthop Clin North Am
2000;31(2):159-176.
52. Reinold MM, Wilk KE, Fleisig GS, et al. Electromyographic analysis of the
rotator cuff and deltoid musculature during common shoulder external
rotation exercises. J Orthop Sports Phys Ther 2004;34(7):385-394.
53. Culham E, Peat M. Functional anatomy of the shoulder complex.
J Orthop Sports Phys Ther 1993;18(1):342-350.
54. Gray H, Clemente CD. The Joints. Anatomy of the Human Body.
Philadelphia: Lea & Febiger; 1985, 329-422.
55. Hong Y, Li JX, Fong DT. Effect of prolonged walking with backpack
loads on trunk muscle activity and fatigue in children. J Electromyogr
Kinesiol 2008;18(6):990-996.