[ RESEARCH REPORT
KRISTOF DE MEY, PT¹š87H87H797=D?;" PT, PhD²š7DD;C?;L7D:;L;B:;"PT³
B?;L;D:7DD;;BI"PT, PhD4š7DDC$9EEBI"PT, PhD4
Trapezius Muscle Timing During Selected
Shoulder Rehabilitation Exercises
houlder pathology in
S general, and impingement,
in particular, are probably
the most common injuries
in competitive and recreational
overhead athletes.1,47 Although
the etiology is considered to be
multifactorial, recent literature
extensively discusses the possible
scapulothoracic contribution to
glenohumeral pathology.28,30,59,61,64
More specifically, various authors
suggest that shoulder injuries
may be linked to abnormalities
in scapular position and move-
ment.20,39,45,53,69 Some authors focus
on global muscle strength weakness,
and others emphasize relative muscle
strength imbalance in the scapulotho-
racic muscles.7,11,12,19,41 Furthermore, mus-
cle recruitment patterns of the scapular
muscles have been examined in over-
head athletes with and without shoulder
pain.9-11,24,29,40,46,58,60,68 In general, these
parameters provide a basis for selecting
exercises and designing protocols for
shoulder rehabilitation and injury pre-
vention purposes.
In patients, deficiencies in muscle re-
cruitment of the different portions of the
trapezius muscle have been identified.
1
Assistant, Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University Hospital, Ghent, Belgium. 2 Assistant Professor,
Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University Hospital, Ghent, Belgium. 3 Researcher, Department of
Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University Hospital, Ghent, Belgium. 4 Professor, Department of Rehabilitation Sciences
and Physiotherapy, Faculty of Medicine and Health Sciences, University Hospital, Ghent, Belgium. The protocol for this study was approved by the Ethical Committee of Ghent
University. Address correspondence to Kristof De Mey, University Hospital Ghent, Department of Rehabilitation Sciences and Physiotherapy, De Pintelaan 185, 2B3, B9000
Ghent, Belgium. E-mail: Kristof.demey@ugent.be
journal of orthopaedic & sports physical therapy | volume 39 | number 10 | october 2009 |
]
Although no general consensus lower trapezius (LT) as showing
exists, several authors describe
the middle trapezius (MT) and
TIJK:O:;I?=D0 Controlled laboratory study.
TE8@;9J?L;I0 To examine the timing of the 3
portions of the trapezius muscle in relation to the
less activation during various dy-
namic activities in patients with
the trapezius muscle (intramuscular timing).
TH;IKBJI0 Intermuscular and intramuscular
differences in timing of the portions of the trape-
posterior deltoid (PD) muscle and in relation to zius muscle were found. The UT was activated
one another during 4 selected shoulder exercises: significantly later than the PD (P .01), and the
(1) prone extension, (2) forward flexion in side MT was activated significantly earlier than the PD
lying, (3) external rotation in side lying, and (4) (P .01), during the prone extension exercise. Dur-
prone horizontal abduction with external rotation. ing the horizontal abduction with external rotation
exercise, the MT (P .01) and the LT (P = .01) were
T879A=HEKD:0 Deficiencies in trapezius
activated significantly earlier than the PD. During
muscle recruitment have been identified in
patients with shoulder pain. Alterations in the
prone extension, side-lying external rotation, and
prone horizontal abduction with external rotation,
trapezius muscle activation level and timing have
significant differences were found between the UT
been identified in previous research. Scapular
and MT, between the UT and LT, but not between
muscle exercises in which the middle trapezius
the MT and LT. In these exercises the MT and LT
(MT) and lower trapezius (LT) muscle showed
were activated significantly earlier than the UT.
optimal activity with minimal upper trapezius (UT)
During forward flexion in side lying, no significant
muscle participation have been recently identified.
However, it is currently unknown if these exercises
timing differences were found between the activa-
tion of the portions of the trapezius.
also promote early activation of the scapular
stabilizing musculature. T9ED9BKI?EDI0 With the exception of the
LT during prone extension, the prone extension
TC;J>E:I0 The intermuscular and intramuscu-
exercise and the prone horizontal abduction
lar timing of muscle activation (based on an activa-
with external rotation exercise promote early
tion level of greater than 10% maximum voluntary
activation of the MT and LT in relation to the
contraction beyond basic activity) of the 3 portions
scapular and glenohumeral prime mover. Taking
of the trapezius muscle during 4 exercises were
into account the limited generalizability of the
examined by surface EMG in 30 healthy subjects on
the dominant side (14 males, 16 females). A 1-sam-
results due to a narrow age range, these exercises
are potentially promising for the treatment of
ple t test was used to determine which portions of
intermuscular and intramuscular timing disorders
the trapezius muscle were activated significantly
of the trapezius muscle. J Orthop Sports Phys Ther
earlier or later than the PD (intermuscular timing).
2009;39(10):743-752. doi:10.2519/jospt.2009.3089
An analysis of variance for repeated measures (3
levels) was used for each exercise to determine TA;OMEH:I0 lower trapezius, middle trapezius,
possible timing differences among the 3 portions of posterior deltoid, scapula, upper trapezius
743
 [ RESEARCH REPORT
glenohumeral instability or impingement,
compared to healthy individuals.7,11,19,39,46,58
Because scapular stability is crucial for
optimal shoulder function and the MT
and LT are considered to be the major sta-
bilizers at the scapulothoracic joint, these
deficiencies might compromise normal
shoulder function and increase the risk
for impingement and instability.26,28,37,38
Based on this assumption, Cools et al8 re-
cently investigated which exercises show
high MT and LT activation with minimal
upper trapezius (UT) participation (low
UT/MT or UT/LT ratio). This was done
to establish which exercises should be
prescribed to restore the scapular muscle
balance and increase scapular stability.
On the basis of this research, 4 exercises
were identified: prone extension, forward
flexion in side lying, external rotation in
side lying, and prone horizontal abduc-
tion with external rotation (<?=KH;').
In addition to dysfunctions in the scap-
ular muscle activation level, the temporal
sequence of recruitment is also found to be
abnormal in patients with shoulder pain
compared to healthy persons. Finally, it is
generally accepted in the literature that an
association between scapulothoracic dys-
function and glenohumeral complaints
exists.42 More specifically, it is described
that athletes with shoulder impingement
symptoms display significantly greater
variability and larger delays in the tim-
ing of trapezius muscle recruitment.10,68
In regard to the different portions of the
trapezius muscle, Cools et al10 established
timing disorders in the MT and LT in re-
lation to deltoid muscle activation. The
temporal sequence of recruitment is as-
sumed to be another important factor in-
fluencing coordination between scapular
motion and humeral elevation.10,28 More
specifically, it is postulated that an early
activation of the stabilizing muscles at
the proximal scapulothoracic joint in re-
lation to prime-mover activation at the
glenohumeral joint is important for main-
taining proper scapulothoracic stability
throughout glenohumeral movement.22,44
Moreover, the scapulothoracic joint al-
most solely depends upon muscle activity
744 | october 2009 | volume 39 | number 10 | journal of orthopaedic & sports physical therapy
]
<?=KH;'$Exercises studied: (1) prone extension, (2) forward flexion in side lying, (3) external rotation in side lying,
and (4) prone horizontal abduction with external rotation.
for its functional stability.43 Consequently,
the results of these studies suggest the
importance of restoring scapular muscle
timing patterns in patients with shoulder
pain. Because muscle timing is found to be
changeable14,68 and, to date, little is known
about which exercises could be efficacious
at the shoulder for promoting early activa-
tion of the MT and LT in relation to the
scapular and glenohumeral prime mov-
ers, the current study examines the timing
of the 3 portions of the trapezius muscle
during the 4 above-mentioned exercis-
es.8,13,66 Hence, 2 research questions were
proposed: (1) in which of the 4 exercises
are the different portions of the trapezius
muscle active before the posterior deltoid
(PD) muscle (intermuscular timing), and
(2) in which exercises are the MT and LT
active before the UT (intramuscular tim-
ing)? We hypothesized that (1) differences
in timing between the portions of the tra-
pezius muscle and the glenohumeral prime
mover (PD) would be found in these exer-
cises, and (2) the exercises would show an
activation sequence in which differences in
timing between UT, MT, and LT would be
found. Where the MT and LT show muscle
activation prior to the UT and PD, these
exercises would be useful for restoring ab-
normal intermuscular and intramuscular
scapular muscles timing disorders.
METHODS
Subjects
T
he data were obtained from a
group of 30 healthy volunteers (14
males, 16 females; mean  SD age,
24.0  2.8 years; body mass, 66.1  14.2
kg; height, 172.9  7.8 cm; body mass in-
dex, 22.0  0.0 kg/m2). Subjects were re-
cruited from the student population and
the local metropolitan area. Twenty-five
were right-handed and 5 were left-hand-
ed. The dominant shoulder was tested
in all subjects. Subjects were included
if they were between 20 and 30 years of
age and able to perform the exercises in a
pain-free range of motion. Subjects were
excluded if they had a history of shoulder
dislocation or surgery, current symptoms
related to the cervical spine, or docu-
mented structural injuries to the shoul-
der complex.10 Subjects participating in
competitive overhead sports or perform-
ing high-level upper extremity strength
training on a regular basis were also ex-
cluded. Exclusion of those participating
in overhead sports was based on the as-
sumption that these athletes would pre-
sumably show some adaptive changes in
muscle timing due to repetitive overhead
movements. Inclusion and exclusion cri-
teria were assessed with a questionnaire.
All subjects gave their written informed
consent to participate in this study, which
was approved by the Ethical Committee
of Ghent University.
Orientation
On the day of testing each subject received
a brief screening examination, signed
the informed consent, and was oriented
to the testing protocol. All testing was
performed on the dominant shoulder,
defined as the arm used to throw a ball.
The protocol was sequenced as follows:
warm-up, electrode placement, practice
and familiarization, maximum voluntary
isometric contraction (MVIC) testing,
and exercise testing.
Electrode Positioning
After a warm-up procedure (shoulder
movements in all directions and pushups
against the wall), the skin was shaved and
prepared with alcohol to reduce skin im-
pedance (typically g10 k8). Bipolar sur-
face electrodes (Blue Sensor; Medicotest,
Ølstykke, Denmark) were then placed
with a 2-cm interelectrode distance over
the upper, middle, and lower portion of
the trapezius and the PD. The PD was
chosen in our study as the glenohumeral
prime mover, because this was the muscle
portion identified as being highly active
during the exercises selected, except for
the forward flexion in side-lying exer-
cise.55,56,65 Electrodes for the UT were
placed midway between the spinous pro-
cess of the seventh cervical vertebra and
the posterior tip of the acromion process
along the line of the trapezius. The MT
electrodes were placed midway on a hori-
zontal line between the root of the spine
of the scapula and the third thoracic
spinous process. The LT electrodes were
placed obliquely upward and laterally
along a line between the intersection of
the spine of the scapula with the vertebral
border of the scapula and the seventh tho-
journal of orthopaedic & sports physical therapy | volume 39 | number 10 | october 2009 |
J78B;' Exercises Studied
Exercise Description
Prone extension The subject is prone, with the shoulders resting in 90° forward flexion. From this posi-
tion the subject performs bilateral extension to neutral position, with the shoulder
in neutral rotation.
Forward flexion in side lying The subject is in side lying position, with the shoulder in neutral along side of the body.
The subject performs 90° unilateral forward flexion in the sagittal plane.
External rotation in side lying The subject is side lying with the shoulder in neutral position and the elbow flexed 90°.
From this position the subject performs maximum external rotation of the shoulder,
with a towel between the elbow and trunk to avoid compensatory movements.
Prone horizontal abduction The subject is prone, with the shoulders resting in 90° forward flexion. From this posi-
with external rotation tion the subject performs bilateral horizontal abduction to horizontal position, with
an additional external rotation of the shoulders at the end of the movement.
racic spinous process. The PD electrodes in external glenohumeral rotation. For
were placed in the middle of the muscle LT testing, performed in a prone position,
belly on the midline between the distal the arm was placed diagonally overhead in
deltoid insertion and the posterior aspect line with the lower fibers of the trapezius.
of the acromion.3,4,8 A reference electrode Resistance was applied against further
was placed over the ipsilateral clavicle. To elevation. For PD testing, the patient was
ensure consistency with electrode place- placed in a seated position, with the arm in
ment, the same investigator placed all a neutral position. Resistance was applied
electrodes. Correct electrode placement against glenohumeral extension. Subjects
was confirmed by visual inspection of the performed three 5-second MVICs against
EMG signals on a computer screen during manual resistance provided by the investi-
specific muscle testing. Each set of bipolar gator. A 5-second pause occurred between
recording electrodes from each of the 4 muscle contractions. A metronome was
muscles was connected to a Noraxon Myo- used to control duration of contraction.
system 2000 electromyographic receiver Before the MVIC recordings, subjects
(Noraxon USA, Inc, Scottsdale, AZ). The were instructed to contract as forcefully
sampling rate was 1000 Hz. All raw myo- as possible and to reach maximal force
electric signals were preamplified (overall as rapidly as possible. After rectification,
gain, 1000; common-mode rejection ra- cardiac artifact reduction, and smoothing,
tio, 115 dB; signal-to-noise ratio, 1 μV the peak average EMG value over a win-
RMS baseline noise, and filtered to pro- dow of 1 second was calculated for each
duce a bandwidth of 10-1000 Hz). trial.8 Data analyses were performed with
the mean of the repeated trials as a nor-
CWn_ckcLebkdjWho?iec[jh_Y malization value (100% MVIC).
9edjhWYj_edCL?9
First, the resting level of the electrical ac- Exercise Description
tivity of each muscle was recorded. Then, After MVIC testing, there was a 5-min-
verification of EMG signal quality was ute rest for each subject. Then each sub-
completed for each muscle by having the ject performed a series of 4 randomized
subject perform maximal isometric con- dumbbell exercises. The exercises were se-
tractions in manual muscle test positions lected based on previous research and are
specific to each muscle of interest.8,27 For presented in J78B;' and <?=KH;'.8 Before
the UT, resistance was applied to abduc- data collection, the exercises were demon-
tion of the arm from a seated position. strated by a member of the research team.
The MT was tested in a prone position Then the subject performed the exercises
and resistance was applied to shoulder without resistance for familiarization
horizontal abduction, with the shoulder purposes, receiving corrective feedback
745
 [ RESEARCH REPORT
Dumbbell Weights (in kg) Used by the
J78B;(
Male Subjects for the 4 Exercises
Subject Weight
Exercises* 50-59 kg 60-69 kg 70-85 kg
Exercise 1 1.5 2.0 3.0
Exercise 2 2.5 3.0 3.5
Exercise 3 2.5 3.0 3.5
Exercise 4 1.5 2.0 3.0
* Exercise 1, prone extension; exercise 2, forward flexion in side lying; exercise 3, external rotation in
side lying; exercise 4, prone horizontal abduction with external rotation.
Dumbbell Weights (in kg) Applied to the
J78B;)
Female Subjects for the 4 Exercises
Subject Weight
Exercises* 50-55 kg 56-64 kg 65-75 kg
Exercise 1 1.5 1.5 1.5
Exercise 2 2.0 2.5 3.0
Exercise 3 2.5 3.0 3.0
Exercise 4 1.0 1.5 1.5
* Exercise 1, prone extension; exercise 2, forward flexion in side lying; exercise 3, external rotation in
side lying; exercise 4, prone horizontal abduction with external rotation.
as needed. Subjects completed 5 trials of different muscle parts was calculated. The
each exercise. Three seconds were pro- muscle signal was considered a contrac-
vided between. Subjects were allowed to tion if it exceeded the trigger level of 10%
rest for 2 minutes between exercises. Dur- of the MVIC beyond basic activity during
ing each exercise, verbal encouragement the concentric phase of the exercise.9,10,57
and, if necessary, performance corrections A lower level, often used in determination
were given by the same examiner. Because of muscle timing activation was not cho-
our aim was to investigate muscle latency sen because it was suggested that this was
times at the beginning of the exercise, too low to investigate the differences in
only the concentric phase of each exercise muscle timing between different muscles.
was used for further analysis. All exercises The same muscle activation level (10%
were performed from a free-weight resting MVIC) was used as in previous research to
position to ensure minimal basic resting enhance the consistency between studies.9
level on the EMG recording. The amount The point in time at which the muscle ac-
of weight used by the subjects was deter- tivity reached this EMG activity level was
mined based on gender and body weight determined. Then, these moments in time
(J78B;I( and 3).8 were averaged for each muscle and each
exercise across the 3 intermediate repeti-
Data Processing tions of the 5 completed repetitions.
All raw EMG signals were analog-digital
converted (12-bit resolution) at 1000 Hz. IjWj_ij_YWb7dWboi_i
After rectification, cardiac artifact reduc- Because the specific topic of interest in
tion, and smoothing, the resting level was this study was to investigate the inter-
determined for each exercise and for the muscular and intramuscular trapezius
4 muscle of interest (UT, MT, LT, and muscle timing, the relative activation of
PD). Then, the muscle activation of the the UT, MT, and LT in relation to the PD
746 | october 2009 | volume 39 | number 10 | journal of orthopaedic & sports physical therapy
]
was first determined. This was done by
subtracting the timing activation values
of the PD from the UT, MT, and LT, re-
spectively. Negative values reflect muscle
activity of the UT, MT, and LT before the
PD. Positive values reflect muscle activ-
ity of the UT, MT, and LT after the PD.
Means (in milliseconds) and standard de-
viations were calculated for the 3 muscle-
timing values for each exercise. Because
all data were normally distributed with
equal variances, parametric tests were
used for statistical analysis.
First, a 1-sample t test (2-tailed) was
used to determine which mean relative
latency times were significantly differ-
ent from 0. This was done to determine
which portions of the trapezius muscle
were activated earlier or later than the
PD. These results represent the inter-
muscular differences in timing from PD.
The forward flexion in side lying exercise
was not included for this analysis because
the PD is not the prime mover for this
movement. Thus, 9 separate 1-sample t
tests without correction were done for the
intermuscular comparison.
Second, an analysis of variance (ANO-
VA) for repeated measures was used for
each exercise to determine possible timing
differences among the 3 portions of the
trapezius muscle, thus representing intra-
muscular variation in timing. The within-
subjects factor for the ANOVA was the
portions of the trapezius muscle (3 levels).
Post hoc analysis was performed using a
Bonferroni procedure when a significant
difference was found with analysis of vari-
ance (B = .05). All statistical analyses were
performed with the Statistical Package for
the Social Sciences, Version 15.0 (SPSS
Inc, Chicago, IL).
H;IKBJI
?dj[hckiYkbWh J_c_d]0 JhWf[p_ki L[hiki
Posterior Deltoid
F
or intermuscular differences
in timing, the 1-sample t test showed
significant differences in mean rela-
tive latency times for 1 or more portions
of the trapezius during each exercise
 (df = 29, t = –2.637) were activated signif-
Muscle Activation Timing of the
icantly earlier than the PD. Results of the
Upper Trapezius, Middle Trapezius,
J78B;* calculations of the intermuscular differ-
and Lower Trapezius in Relation
ences in timing are summarized in J78B;
to the Posterior Deltoid*
4. A schematic representation of the rela-

Muscle/Exercises† Mean SD PLWbk[

tive trapezius muscle timing in relation to
Upper trapezius
the PD muscle is presented in <?=KH;(.
Exercise 1 519 990 .01
Exercise 3 516 611 .01
?djhWckiYkbWhJ_c_d]09ecfWh_ied8[-
Exercise 4 59 586 .57
jm[[dKff[h"C_ZZb["WdZBem[hJhWf[p_ki
Middle trapezius
Because the temporal recruitment within
Exercise 1 –297 432 .01
the trapezius muscle was also of interest,
Exercise 3 13 208 .74
differences between the portions of the
Exercise 4 –243 265 .01
muscle were calculated. The ANOVA
Lower trapezius
revealed significant differences (P .05),
Exercise 1 –148 765 .30
representing intramuscular differences
Exercise 3 5 294 .93
in timing. Post hoc comparisons among
Exercise 4 –363 754 .01
portions of the trapezius showed signifi-
cant intramuscular differences in 3 of the
* Data are in milliseconds (n = 30). Negative values indicate activation prior to the PD. Positive val-
ues indicate activation after the PD. P values based on 1-sample t tests, with 0 (activation of the PD) as 4 exercises studied. During prone exten-
the reference value. sion (df = 2, F = 15.238), side-lying ex-
†
Exercise 1, prone extension; exercise 3, external rotation in side lying; exercise 4, prone horizontal
ternal rotation (df = 2, F = 15.809), and
abduction with external rotation.
prone horizontal abduction with external
rotation (df = 2, F = 8.016), significant
differences were found between the UT
and MT, between the UT and LT, but
Prone extension *
not between the MT and LT. So, in these
*
exercises, the MT and LT were activated
significantly earlier than the UT, without
External rotation in side lying
significant difference between MT and
*
LT. During forward flexion in side lying,
no significant differences were found be-
tween the portions of the trapezius (df =
Prone horizontal abduction 2, F = 0.838). Detailed results of the in-
with external rotation tramuscular differences in timing for the
*
* trapezius are summarized in J78B;+.

–1000 –800 –600 –400 –200 0 200 400 600 800 1000 1200 :?I9KII?ED
UT MT LT

S
capular muscle training is an
essential part of progressive shoul-
<?=KH;($Schematic representation of the activation timing of the upper (UT), middle (MT), and lower (LT) der rehabilitation and injury pre-
portions of the trapezius relative to the timing of the posterior deltoid (PD). The vertical 0 line represents
vention exercise programs.6,23 Because
activation of the PD. Values less than 0 reflect muscle activation before the PD. Values greater than 0 reflect
muscle activation after the PD. Data are means and standard deviations of the timing of muscle activation for the the identification of the specific muscle
UT, MT, and LT in relation to the PD. *Indicates significant differences in muscle timing in relation to PD. Data in recruitment patterns of exercises helps
milliseconds (n = 30). to provide a scientific rationale for their
use, various researchers investigated
(P .05). During the prone extension ex- side-lying external rotation, the UT was the activation patterns of the shoulder
ercise, the UT was activated significantly activated significantly later than the PD muscles during different types of ex-
later than the PD (df = 29, t = 2.871), and (df = 29, t = 4.624). During the horizontal ercises.2,5,8,17,25,32,41,48,51,52,63 However, one
the MT was activated significantly earlier abduction with external rotation exercise, important measure of the muscular co-
than the PD (df = 29, t = –3.760). During the MT (df = 29, t = –5.010) and the LT ordination in the scapular muscles has

journal of orthopaedic & sports physical therapy | volume 39 | number 10 | october 2009 | 747
 [ RESEARCH REPORT ]
of muscle activation between the MT and
Differences in Activation Timing Between
J78B;+ LT was similar.
Sections of the Trapezius Muscle*
In general, shoulder training is fre-
Region/Exercises† Mean SD PLWbk[
quently performed to restore upper ex-
UT-MT
tremity function or to prevent shoulder
Exercise 1 815 160 .01
injury. To achieve these goals, a mul-
Exercise 2 38 57 1.00
titude of exercises are used in clinical
Exercise 3 503 117 .01
practice. Traditionally, the value of an
Exercise 4 302 87 .01
exercise is based on the activation level
UT-LT
at which the different muscles are ac-
Exercise 1 667 182 .01
tivated.5,8,23,52,65 However, performing
Exercise 2 –29 61 1.00
shoulder exercises could also be ben-
Exercise 3 511 125 .01
eficial because of alterations in muscle
Exercise 4 422 122 .01
timing patterns.10 More specifically, it
MT-LT
has been postulated that the timing of
Exercise 1 –149 124 .72
muscle activation of the scapular mus-
Exercise 2 –66 31 .13
cles is an important factor in the rela-
Exercise 3 8 55 1.00
tionship between the dynamic muscular
Exercise 4 120 113 .89
actions and the scapular kinematics.9,10,18
Consequently, an early activation of sta-
Abbreviations: LT, lower trapezius; MT, middle trapezius; UT, upper trapezius.
* Data in milliseconds (n = 30). P values indicate a significant difference in timing between the 2 bilizing muscles at the scapulothoracic
relevant portions of the trapezius. Positive values indicate MT or LT activated prior to the UT. joint could help to increase the scapu-
†
Exercise 1, prone extension; exercise 2, forward flexion in side lying; exercise 3, external rotation in
lar stability to provide a stable platform
side lying; exercise 4, prone horizontal abduction with external rotation.
during glenohumeral movements.28 Fur-
thermore, it is suggested that the stabi-
rarely been studied: the temporal recruit- the prone extension exercise is charac- lizing action of the scapular muscles is
ment pattern during shoulder exercises. terized by high activity of the MT, with essential for an adequate performance
Our study investigated this during 4 fre- minimal UT activation.8,50 The current of the rotator cuff during upper limb el-
quently used exercises. study shows that the MT is also recruited evation.15 If the scapular muscles better
The results of this study largely con- first during this movement. Furthermore, stabilize and synchronize scapular move-
firm our hypotheses. The intermuscular the intramuscular analysis revealed no ments, this could increase the capacity of
timing analysis showed that the MT and significant difference in timing between the rotator cuff muscles to stabilize the
LT were activated before the PD during the MT and LT. Performing horizontal glenohumeral joint. To our knowledge,
prone extension and prone horizontal ab- abduction with external rotation showed muscle timing sequences of the 3 por-
duction with external rotation, support- similar results. This exercise has previ- tions of the trapezius muscle during the
ing our first hypothesis. Furthermore, ously been shown to have high infraspi- above mentioned exercises have not yet
intramuscular timing analysis showed natus activity and was recently selected been the topic of investigation. There-
that for prone extension, external rota- as an adequate scapulothoracic exercise fore, the results of this study are to be
tion in side lying, and prone horizontal based on a low UT/LT ratio.8,65 Kinney seen as a first step in the evaluation of
abduction with external rotation, the et al35 found that the MT and LT show the clinical importance of performing
MT and LT were activated prior to the the greatest amount of activation at 90° exercises with initial MT and LT activa-
UT, supporting our second hypothesis. and 125° of abduction during this move- tion for various goals.
In conclusion, with the exception of the ment in healthy individuals. Our study From a critical point of view, one could
LT during prone extension, the prone confirms the hypothesis that differences also question the relevance of perform-
extension exercise and the prone hori- in muscle timing activation among por- ing these exercises with the objective to
zontal abduction with external rotation tions of the trapezius muscle occur dur- change muscle timing. Although an early
exercise showed activation of the stabi- ing this exercise. The MT and LT showed activation of the stabilizing portions of
lizing portions of the trapezius muscle earlier activation than the UT (intramus- the trapezius seems favorable on a neu-
prior to the glenohumeral prime mover cular timing) and the PD (intermuscular romuscular level, biomechanical stud-
(PD) and UT. timing) in this movement performed at ies demonstrating the advantage during
Previous work from our laboratory 90° abduction. In addition, as well as for functional activities are lacking. Fur-
and other research groups showed that the prone extension exercise, the timing thermore, it remains to be determined if

748 | october 2009 | volume 39 | number 10 | journal of orthopaedic & sports physical therapy
voluntary shoulder movement training
is an appropriate method to improve the
delayed trapezius muscle timing found
as a reflex mediated timing disorder. In
our study, we examined the timing of the
muscle during a volitional arm movement,
whereas in previous research a response
to free falling of the arm was examined.10
Nevertheless, altered muscle timing and
associated positive clinical outcomes after
specific training programs have already
been found in patients with patellofemo-
ral and low back pain.13,14,66,67 Hence, it is
not unlikely that the efficacy of shoulder
muscle training could be related to the
ability to change the timing of the action
of the portions of the trapezius.
Some methodological issues require
special attention in interpreting our re-
sults. First, it must be considered that
the age range of the subjects was narrow,
and that this limits the generalizability of
the results. The reason why young sub-
jects with healthy shoulders were selected
was because the aim of our study was to
define the normal muscle timing of por-
tions of the trapezius during the selected
exercises. However, it must be stressed
that the use of healthy young subjects is
a limitation of the study. Therefore, mus-
cle timing patterns should be the focus
of future research in overhead athletes
and patients with shoulder dysfunction
or pain by using a population-based epi-
demiologic sampling strategy.
Second, some exercise-related factors
should be taken into consideration. For
example, the amount of weight used by
the subjects might have influenced the
recruitment order during the different
movements. Several reasons motivat-
ed the use of low weights in our study.
Relatively low loads are generally rec-
ommended in training done with the ob-
jective to restore scapular neuromuscular
function,43 fatigue was maximally avoided
and the same individualization method
for load determination was used as in
our previous study.8 However, it should
be noted that higher loads are frequently
used in overhead athlete rehabilitation
and that this could influence the recruit-
journal of orthopaedic & sports physical therapy | volume 39 | number 10 | october 2009 |
ment order of the muscles.
Third, the initiation of the movement
itself was not accompanied by a synchro-
nized kinematic evaluation. Although im-
portant limitations occur with kinematic
experiments (eg, skin displacements), it
would give additional information on the
relationship between scapular kinemat-
ics and neuromuscular parameters, such
as the magnitude and timing of muscle
activation. To date, little is known about
the influence of altered scapular recruit-
ment patterns on shoulder biomechanics
and patient symptoms. Future studies
should evaluate this in view of appro-
priate selection of exercises for shoulder
rehabilitative and preventive purposes.
Nevertheless, the starting position,
movement direction, and range of move-
ment were standardized in our study and
the muscle timing was determined with
maximum accuracy.
The use of surface EMG during dy-
namic contractions has been a topic of
discussion in the literature regarding skin
displacement, movement artifacts, influ-
ences of contraction type on the EMG
signal, and normalization methods.16,21 A
considerable effort was made to minimize
the effects of crosstalk. Adjacent bipolar
electrode pairs were generally spaced
more than 2 cm from each other by the
same investigator and recommendations
for muscle specific electrode placements
were followed.3,70
Our results showed high standard de-
viation values, reflecting high individual
variability in muscle timing of the mus-
cles studied. High variability in muscle
timing has also been found by other re-
searchers.10,29,49,57,68 Several reasons could
explain this finding. For example, large
interindividual differences in selective
motor innervations of each subdivision
of the trapezius muscle by the cranial
and spinal accessory nerve are described
based on anatomical research. 33,34,54 Dif-
ferent innervational supply to a muscle
could possibly influence the motor out-
put to the different portions of the tra-
pezius. Also, the sensitivity of the testing
procedure used to determine muscle
timing is to be considered. In the lit-
erature, different methods are used to
determine the timing of muscle activ-
ity and multiple influencing factors are
also described.9,57,62,66 Although the ac-
tual rise time of the EMG signal may be
altered by the processing used, the same
standardized procedure was utilized as
in our previous research to ensure maxi-
mum comparability between studies. 9
Some limitations should be men-
tioned from a clinical point of view.
During functional activities, such as
arm abduction in the scapular plane,
Wadsworth et al68 stated that an initial
activation of the UT is normal and is re-
quired for optimal scapula contribution
to shoulder complex elevation. During
sport-specific movements (eg, serving
in tennis), a general proximal-to-distal
activation pattern has been found. Yet,
it was recently demonstrated that the
muscle activation at the shoulder dur-
ing these movements also consists of
an activation of the UT before the LT
in healthy athletes.29 Because reha-
bilitation and conditioning programs
should be designed with the activation
sequences found in the sport-specific
movements, one could focus on an ac-
tivation pattern opposite to that postu-
lated in this study. However, Kibler et
al32 stated recently that exercises with
initial UT activation should merely be
performed in later phases of rehabilita-
tion. Therefore, we propose our exer-
cises to be performed in early stages of
rehabilitation, with the objective of pro-
moting early activation of the scapular
stabilizing musculature. This investiga-
tion presents data on relative scapular
muscle timing for several exercises and
theorizes regarding preferential exercise
selection. Ultimately, the choice of the
most appropriate exercise for a patient-
specific condition remains theoretical
until comparative effectiveness research
is presented in the literature.
It should be noted that the function
of the scapular muscles during functional
activities is characterized by a synergistic
action of muscles to produce 3-dimen-
749
 [ RESEARCH REPORT
sional movements of the scapulothoracic
joint.44 Because they do not work in iso-
lation, it remains to be determined to
which extent isolated training targeting
the stabilizing portions of the trapezius
can change the muscle activation tim-
ing during functional activities, such as
throwing. The rationale that this could be
possible is based on the finding that the
UT, MT, and LT participate in different
ways to control scapulothoracic move-
ment and on previous research showing
that the timing of muscle activation can
be changed by physical therapy treat-
ment.13,26,66 However, to date, it is still not
clear whether temporal changes in scapu-
lar muscle activation can be induced by
shoulder training. The possibility exists
that muscle timing activation patterns in
patients are carried over to the exercise.
This would diminish the clinical effective-
ness in individuals with dysfunction or
patients with shoulder pain. The results
of this study should also consider serra-
tus anterior muscle function and not be
interpreted isolated from other scapular
muscle contributions.36,39
Finally, the exercises studied are all
traditional exercises performed in a ly-
ing position (prone or side lying), while
integration of shoulder movements in a
kinetic chain is promoted strongly in re-
cent literature.31,48 Therefore, we propose
that our exercises be performed prior to
more complex exercises performed in
more functional positions.
On the basis of our research question
and our results, we believe further exami-
nations should be performed. First, more
research should be done on the trapezius
muscle timing characteristics in healthy
and injured athletes under various con-
ditions. Both muscle reaction times and
muscle recruitment patterns during vol-
untary shoulder movements should be
studied. Second, it should be investigated
which, if any, biomechanical advantages
are associated with an early activation
of the MT and LT. Third, little is known
about the muscle recruitment patterns
during other exercises and during sport-
specific movements. More knowledge
750 | october 2009 | volume 39 | number 10 | journal of orthopaedic & sports physical therapy
]
in this area may benefit many aspects
of athletic and sport-specific rehabilita-
tion. Fourth, the short- and long-term ef-
fects of trapezius muscle training on the
timing of the different muscle portions
should be determined by prospective re-
search in view of an effective injury reha-
bilitation or preventive shoulder training
program.
9ED9BKI?ED
O
ur results suggest that, with
the exception of the LT during
prone extension, the prone exten-
sion exercise and the prone horizontal
abduction with external rotation exercis-
es promote early activation of the MT and
LT in relation to the UT and glenohumer-
al prime mover (PD). Taking the limited
generalizability of results into account,
these exercises are potentially useful in
the treatment of trapezius muscle timing
disorders. Further prospective research
in both overhead athletes and patients
with shoulder pain is mandatory to sub-
stantiate this assumption. T
A;OFE?DJI
<?D:?D=I0 With the exception of the
LT during prone extension, the prone
extension and the prone horizontal ab-
duction with external rotation exercise
promote early activation of the stabiliz-
ing portions of the trapezius muscle
(MT and LT) in young healthy subjects.
?CFB?97J?ED0 These findings help to in-
form decision making with regard to
exercise prescription for shoulder reha-
bilitation. Because previous studies have
shown that the MT and LT had delayed
activation in subjects with shoulder
impingement symptoms, performing
these exercises may be potentially useful
in the treatment of timing alterations of
the trapezius muscle.
97KJ?ED0 Generalization of the results is
limited because of the narrow age range
and healthy subjects tested in this study.
This study does not provide data on ef-
fectiveness of these exercises in rehabili-
tation for those with shoulder pain.
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of the scapula reposition test on shoulder im- patterns of the scapular rotator muscles in WWW.JOSPT.ORG

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752 | october 2009 | volume 39 | number 10 | journal of orthopaedic & sports physical therapy