Evidence based Shoulder Exercises – How To Treat Muscle Imbalances

 

This isn’t your average rotator cuff and scapula article. We will be demonstrating and explaining seven evidence based shoulder exercises. Principles of biomechanics, kinesiology, and electromyography will be explained and you’ll learn how to increase targeted muscle activation, improve scapular muscle activation sequencing, and challenge shoulder stability. We are taking broscience to the next level, providing research and evidence based approaches to prehab the shoulder for longevity. 

 Evidence Based Shoulder Exercises

Shoulder and neck pain and dysfunction are among some of the most common complaints of the overhead athlete and desk-bound worker alike. Recent research has shone light on the importance of the scapular muscles in shoulder and neck pain and dysfunction. The scapula serves as our shoulder’s stable base. We need a strong and stabilized scapula in order for our shoulder joint to move properly. Proximal stability promotes distal mobility, folks! Based on research, overhead athletes are more likely to recruit the upper traps prior to lower or middle trap. This can lead to a timing issue in terms of muscle recruitment. Because of this, lower and middle trapezius and serratus anterior activity may decrease, while upper trapezius, pec minor, and levator scapula activity may increase. This group of dysfunctions can lead to decreased scapular upward rotation, external rotation, and posterior tilt – all specific scapular motions that are imperative to maintaining the subacromial space and preventing things like shoulder impingement and rotator cuff tendinopathy.

Selective Muscle Activation

The glenohumeral joint, aka the shoulder, is so fascinating to the anatomist because it demands chronologic, selective muscle recruitment. The trapezius muscle is made up of three primary fibers: upper, middle, and lower. As a unit, these muscle fibers should activate at specific times with balanced force couples to help move the arm in various directions. Work, hobbies, sports, and performing repeated movements will reinforce movement patterns in the brain, regardless of whether those movements are good or bad. Altered muscle activity and recruitment patterns may increase stress on structures, which may cause mechanical pain or injury.

How do we fix this? By training the brain to learn a new movement pattern. Learning and performing selective muscle activation sequences during specific movements is a way to tap into the nervous system. Here we show one way to train the brain via biofeedback. This is an electromyography device that uses surface electrodes placed on the upper trapezius. Listen to the different cues Mike provides Craig and listen to the change in muscle activity measured by the biofeedback device. We understand that not everyone has this machine at their disposal, however, visual and tactile cues can be used to accomplish the same goal.

Sharapovas

Maria Sharapova (@mariasharapova), the former world #1 women’s tennis player has had quite the remarkable career. But before she reached that #1 spot, she had to battle through a host of well-documented shoulder injuries that hampered her career early on. Rumor has it that this exercise in particular helped REHAB and [P]REHAB her shoulder back to health, hence the aptly named “Sharapova” exercise. It’s an absolute rotator cuff killer that hits the infraspinatus and teres minor isometrically, concentrically, and eccentrically.

HOW TO PERFORM: 

• Keep your elbows and hands against the wall. Maintain tension in the theraband the ENTIRE TIME. 
• As you move one arm up (right hand for example), ensure that your left hand is anchored and doesn’t move, this will isometrically challenge your left rotator cuff. 
• As you move your right hand up, make sure to move in a curved “C” pattern. This allows you to eccentrically and then concentrically challenge the right rotator cuff. 
• I like to shoot for 3 “in and outs” per side on the way up, and then 3 more on the way down. That’s 1 rep. I shoot for 5 reps before taking a break and boy, will you feel the burn! 
• Note: A similar exercise (Castelein et al 2015) was found to decrease upper trapezius and pectoralis minor activation, while increasing middle trapezius, lower trapezius, and rhomboid activation.

90/90 Scapular Stabilization

The upper trapezius becomes can overpower the middle and lower traps when it is too strong and hyperactive. The middle and lower trapezius are just as important during overhead exercises to promote optimal mechanics. More importantly, we have to learn how to activate the trapezius as a stabilizer, rather than a mobilizer, during certain glenohumeral joint motions.

Here is a great exercise to increase mid and lower trap muscle activation. According to Maenhout et al 2016, the highest middle trapezius and lower trapezius muscle activation was found in prone exercises. Why is training the scapular stabilizers at a 90/90 degree shoulder abduction and external rotation so important? Well look how familiar this position is; think of a pitcher throwing or a CrossFit athlete performing an overhead movement. The shoulder is vulnerable in this position due to the risk of instability of the anterior/inferior glenohumeral joint capsule. Also, the labrum is speculated to be weak in this position. Therefore, we have to train our scapular stabilizers and rotator cuff to be strong in this position!

 Be sure to avoid hiking your shoulders into your ears and keep your elbow relatively stable with as little movement as possible during this exercise. Note: I tried to exaggerate excessive upper trap use in the first rep!

Overhead Carries

Any form of a loaded carry is always a go-to exercise. This is especially true for overhead carries, which are a great way to train proper shoulder muscle recruitment under heavy load. You need good lower trapezius, serratus anterior, and upper trapezius muscle activation to maintain a stable, upwardly rotated scapula. Not only that, but the ability to maintain a stable humerus in the overhead position places a huge demand on the rotator cuff. 

In this first overhead carry sequence, I demonstrate a passive vs active overhead carry position. The goal here is to maximally activate the scapular upward rotators to provide a stable base when under an overhead load. In the video, I point to the bottom part of my scapula, known as the inferior angle, to provide a cue to get maximal lower trapezius and serratus anterior activation (relative to the upper trapezius). The cue I like to use with my patients is to “point the bottom of your scapula forward.” I find this helps promote scapular posterior tilt and external rotation (in addition to proper scapular upward rotation).

In the last overhead sequence, I demonstrate what we DO NOT want to see – excessive upper trapezius recruitment and subsequent scapular elevation instead of upward rotation. Making sure to maintain a nice window of space between your neck and shoulder is a great way to ensure you’re not excessively using your upper traps.

Trapezius Muscle Balancing Exercises

These 4 exercises were found to display the BEST muscle activation ratios in which upper trapezius activation is minimized and middle and lower trapezius activation is maximized by Cools et al 2007. The prone and sidelying positions decrease the upper trap’s activation as a postural muscle. When you stand, the upper trap is more active as its working against gravity. Laying on your stomach or side eliminates the effects of gravity and can decrease excessive activation!

Plyometric Serratus Anterior Push-Ups

Scapular muscles play a huge role in controlling and stabilizing shoulder movement. One cannot address the shoulder without first addressing the scapula. The serratus anterior is among the important anterior scapular muscles. Scapular winging (i.e. SICK scapula) is a condition where the medial scapular border moves away from the rib cage. Think of the shoulder blades being close together in a resting position, similar to a bird with it’s wings closed. Now picture those wings ‘opening up’ when the bird goes to fly. When humans move their arms overhead, the shoulder blades should should only move away from one another, NOT the ribs.
Scapular winging could be caused by an anterior scapular stabilization issue due to a motor control problem or muscular weakness. 

In order to fix this movement pattern, you have to perform exercises that INCREASE the recruitment of the anterior scapular stabilizing muscles, specifically the serratus anterior. Here is a plyometric bosu ball push up exercise shown with a regression and progression. 

According to Maenhout et al. 2016, this exercise increases serratus anterior activity in the backward push off phase GREATER than the landing phase. This is a great exercise for athletes who are returning to sports AND those who are currently playing. Note: this exercises is challenging for me, so I need to practice it more.

Dynamic Scapular Stability Drill

Demonstrated here is a dynamic mobility and stability drill for anterior scapular muscles. The important thing to appreciate and recognize is that this movement is different than just moving your arm freely in all directions on the wall. As I do the exercise, I apply a constant isometric force by pressing my hand into the wall as I move the slider. This external cue of ‘push into the wall’ recruits the anterior scapular musculature (eg serratus anterior and pec minor muscles) to be active and provide scapular stability. 

Demonstrated here is a dynamic mobility and stability drill for anterior scapular muscles. The important thing to appreciate and recognize is that this movement is different than just moving your arm freely in all directions on the wall. As I do the exercise, I apply a constant isometric force by pressing my hand into the wall as I move the slider. This external cue of ‘push into the wall’ recruits the anterior scapular musculature (eg serratus anterior and pec minor muscles) to be active and provide scapular stability. 

The particular sequence of scapular movements I demonstrate is as follows: 

1) protraction and upward rotation 

2) protraction

3) protraction and downward rotation+depression

4) protraction and upward rotation+elevation

In summary, we are working shoulder blade mobility and stability in all directions!

It is important to note that performing closed-chain exercises similar to this (hand on wall) increases activity of the rotator cuff muscles. Increased activity of these muscles increases dynamic stability of the shoulder during movements. Remember, the rotator cuff muscles do not move the shoulder! They originate on the scapulae and insert on the humerus. This anatomical arrangement dictates that the rotator cuff’s specific job is to provide dynamic stability to the glenohumeral joint. It’s what help keeps the humeral head within the glenoid fossa during any movement. Proximal stability at the shoulder will facilitate optimal distal mobility.

Bulletproof Shoulder [P]rehab Warm-up

Your warm-up should always incorporate priming your nervous system and target muscles for your specific lifts. This is one of my favorite shoulder warm-ups, with inspiration taken from @drjohnrusin and @thebarbellphysio. I’ll break down the 3 parts of the warm-up and tell you why you should be incorporating them too:

1) Face-Pull: This exercise is a modified row movement. It targets the RHOMBOIDS and more importantly, the MIDDLE TRAPEZIUS to get good activation. Additionally, EMG studies have shown that the face-pull has one of the highest average and peak EMG activities for the posterior AND middle deltoids, too!

2) Shoulder external rotation in a 90/90 position: This exercise achieves concentric, eccentric, and isometric activation throughout. It also induces the exact same shoulder position of any overhead movement like the press or snatch. Strengthening in this position is key for functional carry over into crossfit.

3) Resisted Y-Upward Rotation: This exercise primes your serratus anterior, upper traps, AND lower traps due to the particular angle of the arm in the scapular plane.

BOOM. Now get out there and hit some new [P]Rs. Tag a friend or share with someone who needs some shoulder [P]REHAB!

References

1. Cools AMJ, Struyf F, De Mey K, Maenhout A, Castelein B, Cagnie B. Rehabilitation of scapular dyskinesis: from the office worker to the elite overhead athlete. Br J Sports Med. 2014;48(8):692–697.
2. Castelein B, Cools A, Bostyn E, Delemarre J, Lemahieu T, Cagnie B. Analysis of scapular muscle EMG activity in patients with idiopathic neck pain: A systematic review. J Electromyogr Kinesiol. 2015;25(2):371–386.
3. Maenhout A, Benzoor M, Werin M, Cools A. Scapular muscle activity in a variety of plyometric exercises. J Electromyogr Kinesiol. 2016;27:39–45.
4. Cools AM, Dewitte V, Lanszweert F, et al. Rehabilitation of Scapular Muscle Balance: Which Exercises to Prescribe? Am J Sports Med. 2007;35(10):1744–1751.