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The Role of the Scapula

Russell M. Paine PT' Michael Voight, MEd, PT, ATC, SCS2

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I
A

Russell M. Paine

Michael Vo~ght

The scapular musculature is often neglected in designing a rehabilitation protocol for the shoulder. Weakness of the scapular stabilizers and resultant altered biomechanics could result in: 1) abnormal stresses to the anterior capsular structures of the shoulder, 2) increased possibility of rotator cuf~compression, and 3) decreased pedormance This article presents known facts about the biomechanics of the scapula and surrounding muscles and suggests methods for evaluation of scapular muscle weakness. Exercise techniques to maximally strengthen the scapular musculature are also described. As our ability to document strength of these muscles improves, we will be able to determine the effect of scapular strengthening on improving symptoms related to impingement and instability. Scapular strengthening exercises are usually nonstressful to the rotator cuff and are easily implemented into a rehabilitation program for the shoulder.

Key Words: scapular musculature, biomechanics, muscle strengthening

he role of the scapula has recently received renewed interest as knowledge of the shoulder and surrounding structures has increased. In normal upper-quarter function, the scapula provides a stable base from which glenohumeral mobility occurs. Stability at the scapulothoracic joint is dependent upon the surrounding musculature. These scapular muscles dynamically position the glenoid so that efficient glenohumeral movement can occur. T h e scapula has been described by several authors as a vital component in overhead throwing motion (4.7.8). Kibler has studied the position of the scapula and believes that alteration of normal positioning can lead to altered biomechanics of the shoulder (7). When weakness is present in the scapular muscuI;~turc,normal scapular positioning and mechanics may become altered. Efficient concentric and eccentric activity of the musculature surrounding the shoulder is dependent on having strong anchor muscles to stabilize the scapula.
386

' Director of Sportsmedicine Research and Associate Clinical Director, Rehabilitation Services of Houston, 6560 Fannin #2040, Houston, TX 77030 Instructor, University of Miami School of Medicine, Division of Physical Therapy, Coral Gables, F1; National Director of Sports Medicine, Sports Physical Therapist, Inc., Bryn Mawr, PA

Without a strong, stable base position, the scapula may slide laterally, thereby allowing the glenoid fossa to become more "antetilted," which will place excessive stress on the anterior structures (7). Saha has also described the antetilted position as a possible component of the subluxation/dislocation phenomena in patients who have undergone repetitive microtrauma (9).

Serratus Anterior
T h e serratus anterior is an important scapular stabilizing muscle. It takes origin from the first eight ribs and courses along the rib cage to insert along the medial aspect of the scapula. T h e upper portion of the serratus anterior insertion is spread along the medial border of the scapula, while the lower portion inserts into the inferior angle of the scapula. Innervation t o the serratus anterior is provided by the long thoracic nerve, which arises from the ventral rami of the fifth and seventh cranial nerves. Due t o the multiple attachment sites, the primary role of the serratus anterior is to stabilize the scapula during elevation and t o pull the scapula forward and around the thoracic cage. Advancement of the scapula t o an anterior position on the thoracic cage is termed protraction o r scapular abduction. T h e term protraction is more frequently
Volume 18 Number I July 1993 JOSPT

FUNCTIONAL ANATOMY AND BIOMECHANICS

It is important that the clinician have a thorough understanding of the muscles that control the scapula and normal scapular mechanics. Only through an understanding of normal biomechanics can the pathomechanics of i~i.jirryo r dysfunction be understood. When describing the position of the sc;~pula, the point of reference is the glenoid.

used in describing this anterior niovement in order to avoid confirsion with slior~lder abduction. T h e movement of protraction is involved with pushing and punching type activities.

(4). Thereforc~, the strength of t hc rhomboids is vital in throwing and overhead ;mil niovenient . Strengthening this m~rscle group should be enipliasi7ed when rehi~hilitating patients with anterior instability.

Rhomboids
T h e rhomboids (niqjor and niinor) function to stabilize the medial horder of the scapula. T h e rhomboids are verv active in scapular adduction o r retraction. which can be defined as backward rotation of the scapula toward the vertebral column. T h e rhomboid minor takes origin from the spinous process of the seventh cervical and first thoracic vertebrae and inserts into the medial border of the scapula near the base of the scapular spine. T h e rhomboid mqjor originates from the second through fifth thoracic vertebrae and inserts into the medial horder of the scapula just below the insertion of the minor. Innervation to both the rhomboid major and minor is provided by the dorsal scapular nerve. If rhomboid weakness is present, the scapula will be unable t o achieve full retraction. Full retraction is essential not only for overhead throwing motion but also for swimming strokes such as the crawl. T h e inability t o achieve the fully retracted position during the throwing o r overhead motion can lead to increased stress on the anterior structures of the shoulder (7). Activities that involve a pulling motion may be affected by lack of rhomboid strength. Electromyographic analysis has demonstrated a high level of rhomboid activity during the acceleration phase of pitching (4). This suggests that the rhomboids are contracting eccentrically to provide stabilization t o the medial border of the scapula during acceleration (4). T h e r e is also high rhomboid electromvographic activitv during the followthrough phase of throwing as the muscle contint~es to contract eccentrically t o "brake" the energy released during acceleration JOSPT \'olrrme 18 Number 1 *lrtly 1999

Upper Trapezius/Levator Scapulae

T h e upper trapeirius and levator scapulae muscles are suspensorv muscles of the scapula. T h e upper trape7ius originates from the superior nuchal line, the external occipital protuberance of the skull, and the seventh cervical vertebra. T h e upper trape7ius fibers course downward to insert into the distal third of the scapula. Innervation t o the u p per t r a p e 7 i ~ is provided bv the spinal accessory nerve. T h e levator scapula originates from the posterior tubercles of the transverse processes of cervical vertebrae 1-4. T h e insertion of the levator scapula is along the medial border of the scapula at the level of the scapular spine. Innervation is provided bv the cervical plexus with frequent contribution by the dorsal scapular nerve. Minimum upper trapezius electromvographic activitv has been reported in quiet standing (10). Adding a weight t o the hand o r elevation of the sci~pula initiates a strong contraction of both the upper trapezius and levator scapula (11). T h e upper trape7iirs has also been shown t o be constantly active during anibulation t o perform its suspensorv role (I). In addition t o its sllspensorv function, the upper trape7ius assists in upward rotation of the scapula. which is criticill in the niovernent of the arm overheid. If the lrpward rotation of the scapt~li~ is not effective, sirhi~cromial impingement niav occur.

Pectoralis Minor
T h e pectoralis minor is an anterior muscle that takes origin from the axial skeleton (second through sixth ribs) and inserts into the medial aspect of the coracoid process on the

sci~pul;~. T h e pectoralis minor is innerv;~tedbv t lie medial-lateral pecto.I I'1s minor ral ncrves. l ' h e pectorfunctions to p e r h r n i several niovements: abduction, depression, downward rotation, and upward tilt of the scapula. With normal physiologic movement, the scapular muscles act in concert with one another. Recause each muscle is made up of multiple fibers that course in different directions, each muscle mav have multiple fimctions. T h e trapezius retracts and elevates the scapula. T h e rhomboids and levator scapulae primarily retract and rotate the scapula downward. T h e serratus anterior rotates the scapula upward and protracts the scapula. An important force couple exists to allow forward rotation of the scapula. A force couple is the action of two forces acting in opposite directions t o impose rotation about the axis (6). T h e lower fibers of the serratus draw the lower angle of the scapr~la forward t o couple with the trapezius and levator scapr~lae in forward rotation (6). Inman et al also describe the role of the levator scapulae and upper trapezius in assisting with upward rotation of the scapula (5). Thev describe the levator scapulae as the ~rpward force unit rather than the lower fiber of the serratus. T h e lower force unit is described as consistent activity of the fourth and fifth digitations of the serratus anterior. T h e seventh and eighth digitations display less activitv in the last degrees of abduction. which allows the angle to remain in the coronal plane. As the serratus anterior and upper trape7i11sprovide upward rotation i ~ n d sti1hili7;1tion of tlic scaprrla, the deltoid is able to assert its action on the humerus and not the scapula (2). This coupling effect was confirmed by Mosely et al. who performed electromyographic analvses during severi~l scapular exercises (8) (Table 1). T h e force coi~ple provides an extremelv important function with upward rotation of the acro-

CLINICAI, COMMENTARY

Muscle
Upper trapezius Middle trapezius 'Lower trapezius Levator scapulae Rhomboids Middle serratus anterior Lower serratus anterior Pectoralis minor

Exercise Rowing Horizontal ABD (neutral) Rowing ABD Rowing Rowing Horizontal ABD Flexion Push-upswith a plus Press-up

% of MMT

Function Retraction Retraction Retraction Upward rotation Retraction Retraction Retraction Upward rotation and protraction Upward rotation and protraction Depression

MMT = manual muscle test. Mosely (8) periormedan EMC analysis during several rehabilitationexercises. The values reported were expressed as a percentage o i a maximum isometric muscle test that was performed for each muscle.

TABLE 1. Most efficient exercises for specific muscles.

mion away from the humerus in forward elevation of the shoulder, thereby preventing impingement.

EVALUATION OF SCAPULAR STABILITY

T h e important stabili7ation function of the serratus anterior is dramatically presented in patients with extreme weakness o r damage t o the long thoracic nerve. When carrying objects in front of the body, these patients will demonstrate severe winging of the scapula, which produces a strong contraction of the serratus anterior t o prevent backward rotation of the scapula. Scapular winging has been traditionally demonstrated by having the patient push against the wall with his hands just below the waist (Figure la). If the serratus anterior and other stabilizers a r e weak, the scapula will rotate backward o r wing. Another method to demonstrate scapular winging is t o ask the patient t o forward flex the shoulder to 90 (Figure 1b). If the serratus anterior is not performing its stabilizing function, the most dramatic effect will be observed in the first 45' of elevation as the scapula seeks the optimal position to allow for efficient glenohu-

meral rotation. It is important t o conduct a bilateral examination, since slight winging may be normal in individuals with normal hypermobility. Current treatment techniques to increase scapular stability have been developed, and positive clinical results have been observed. T h e most dramatic effects have been seen in patients with significant scapular winging. T h e limiting factor in ob-

The most dramatic effecfs have been seen in patients with significant scapular winging.

FIGURE 1. A) This position demonstrates winging of the scapula by having the patient push into the wall with the hands below the waist. The serratus anterior contracts to prevent backward rotation of the scapula. Iiweakness is present unilaterally, winging will be observed. B) This technique allows the clinician to view scapular winging during dynamic elevation of the arm. Resistance from the rubber tubing iorces maximum contraction o i the serratus anterior to stabilize the scapula. Weakness will be observed unilaterally as scapular winging. We have found this technique to be more effective in demonstrating lack o i scapular stabilization.

jectively identifying the significance of these clinical results has been the inability t o accurately document deficits and improvements in strength of the scapular musculature. Kibler has described the lateral scapular slide measurement, which measures the ability of the scapular stabilizers

to control the medial border of the scapula (7). An increase of 1 cm o r more in side-to-side measurements was reported to correlate directly with symptoms of pain and decreased shoulder function. Reproducibility and reliability of determining the point of reference on the
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C1,INICAI. C O M M E N T A R Y

scapula t o measure movement is difficult to achieve. lsokinetic testing of protraction and retraction as a means t o quantify scapular strength is currently underway. T h e early results of day-to-day reliability have been promising.

SCAPULAR STRENGTHENING EXERCISES Serratus Anterior

Mosely has described the pushu p with a plus as an effective method to strengthen the serratus anterior (8). This exercise is performed by having the patient perform a prrshU D with full s c a ~ u l a ~ r rotraction at the top of a push-up (Figure 2). If patients are either unable to complete o r tolerate this exercise, they may begin the push-up with a plus in the standing position with their hands against the wall (Figure Ja). T h e standing push-off progression allows the therapist t o gently "push"
FIGURES 3A and B. Push-niic allo\v the patient to perinrrn a c l o d krnetic chain exercise. This exercise will strengthen all shoulder girdle muscles, with emphasis on the pectoralis major and minor. Progression to a therapist-assisted wall push brces the patient to perform both concentric and eccentric contractions.

and perform a punching motion t o allow maximal protraction. Manual resistance can be provided t o the an5). Resistterior s h o ~ ~ l d(Figure er ance may also be applied through the long axis of the arm. Additional forms of resistance can be provided through the use of dumbbells, the body blade (Hymanson, Inc., Playa Del Rey, CA), and surgical tubing (Figure 6). As previously mentioned, isokinetic devices that allow scapular protraction/retraction provide ;In aggressive means of strengthening the scapular musculature (Figure 7).

Middle Trapezius/Rhomboids
Strengthening the middle trapezius and rhomboids begins with s/m-

FIGURE 4. Quadruped stabilization. Th~s exercise is another closed chain activity. The patient focuses on controlling the scapula oi the weight-bearing limb while the therapist manually resists elbow flexion and extension m the opposite extremity.

FIGURES 2A and B. Push-ups with a plus. This exercice was shown by Mosely et a1 to have the highest electromyographic activity for the serratus anterior. The exercise is performed by executing a normal push-up, followed by an extra "push" to the ceiling to allow full protraction. The digitations of the serratus can be observed in the "plus" position.

the patient into the wall (Figure Jb). An efficient eccentric contraction is produced as the patient catches himself and decelerates. Quadruped stabilisation is another closed kinetic chain exercise that stimulates proper stabilization of the scapula (Figure 4). T h e goal of this exercise is for the patient to try t o control scapular winging that may be present while the therapist provides manual resistance t o the uninvolved arm. T h e punching (standing o r supine) motion is another effective exercise for strengthening the serratus anterior. Patients elevate their shoulders t o 00' with the elbow extended

FIGURE 5. Manual resisted protraction and retraction allow isolation of the proximal muscles Hand placements are the anterior aspect of the shoulder and the distal spine of the scapula. 389

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CLINICAL COMMENTARY

rhomboids is the bent-over lateral raise.

Upper Trapezius/Levator Scapula

T h e upper trapezius and levator scapula can be exercised by perform-

ing shoulder shrugs with tubing. This exercise may also be performed using hand-held dumbbells for resistance. We prefer rubber tubing over dumbbells in patients suspected of having an inferior t o multidirectional instability a t the glenohumeral joint. Long axis distraction, when using heavy dumbbells, may exaggerate the inferior glide of the humeral head and should be avoided. An al-

FIGURES 6A and B. A punching motion in the standrng position will strengthen the serratus anterior muscle. This device is a home exercise product (scapular strengthening kit-Breg, Inc., Carlsbad, CA) that assists in developing scapular strength. The patient is instructed to fully protract the scapula by reaching forward. The patient then slowly returns the hand to the starting position as he focuses on controlling the scapula.

FIGURE 7. lcokrnetrc protactron and retraction are periormed with a new closed cham attachment (Biodex, Shirley, NY). This instrument will help to document weakness of the serratus and rhomboid musculature.

Long axis distraction, when using heavy dumbbells, may exaggerafe the inferior glide of the humeral headand should be avoided.

ple pinching together of the shoulder blades. This is a relatively painfree exercise that may be incorporated into the early stages of most shoulder rehabilitation programs. Isolation of the middle trapezius and rhomboids may be accomplished through the use of manual resistance (Figure 5). Resistance may also be provided with dumbbells, machine cable columns, and rubber tubing. Moselv demonstrated a high level of electromyographic activity with the seated row (8). An effective method of performing the seated row is the use of the scapular strengthening device (Breg, Inc., Vista, CA). Proper technique is important t o allow full scapular protraction and retraction (Figure 8). T h e elbows must remain tuc&ed to the side during to the Another high-level strengthening exercise for the middle trapezius and
390

ternative method of strengthening is the use of manual resistance on the top of the scapula and clavicle. This method removes the stress applied t o the inferior capsule of the glenohumeral joint.

Lower Trapezius/Pedoralis Minor

Mosely showed a high level of electromyographic activity in the lower trapezius and pectoralis minor while performing the press-up exercise (8).

CONCLUSION
T h e shoulder must be considered a kinetic chain made up of severa1 joints. T h e function of ;he s c a p ula and surrounding musculature is vital to the overall normal function of the shoulder. Rotator cuff strengthening has been an obvious treatment for various pathologies. Since the origins of the rotator cuff
Volume 18 Number 1 July 1993 JOSPT

FIGURES 8A and B. The seated row erercice i e excelirnt tor aggrecsive strengthen~ngoithe rhomboids. Proper technique is important. Using the scapular strengthening kit, the subject reaches forward to allow full protraction, followed by full retraction of the shoulder blades. The elbows must ,ma;n tucked as the handle is pulled ;,,to [he chest while the shoulder blades are pinched.

CLINICAL COMMENTARY

muscles arise from the scapula, an effective exercise regime for rehabilitation should include improving strength and function of the muscles that control the position of the s c a p ula. Weakness of these anchoring muscles may lead to altered biomechanics of the glenohumeral joint with resultant excessive stress imparted t o the rotator cuff and anterior capsule. Advancement in the knowledge of biomechanics and electromyographic patterns of the shoulder have allowed us t o develop strengthening exercises that maximally strengthen these "anchor" muscles. T h e three basic activities t o remember when designing a scapular strengthening program a r e scapular pinches, shrugs, and punches. T h e choice and intensity of specific exercises are determined by pain and associated pathology.

Through proximal strengthening, many shoulder problems can be improved. JOSPT

Elbow Surg 1: 15-25, 1992 5. Inman IT, Saunders M, ~ b b o t L: t Observations on the function of the shoulder joint. I Bone joint Surg 26:l-30, 1944 Kent B: Functional anatomy of the shoulder complex. A review. Phys Ther 5 1:867-887, 1971 Kibler BW: Role of the scapula in the overhead throwinn motion. C o n t e m ~ Orthop 22:525-5i2, 199 1 Mosely BI, lobe FW, Pink M, Perry 1, Tibone I: EMC analysis of the scapular muscles during a rehabilitation program. Am I Sports Med 20: 128- 134, 1972 Saha AK: Mechanics of elevation of glenohumeral joint. Its application in rehabilitation of flail shoulder in brachial plexus injuries and poliomyelitis and in replacement of the upper humerus by prosthesis. Acta Orthop Scand 44:668, 1973 Shoo MI, Perry I: The shoulder girdle muscles in transfer, an electromyographic study. Resident Seminars, Rancho Las Amigos Hospital, 1978

6. 7. 8.

REFERENCES
Ballesteros MLF, Buchthal F, Rosenfalk P: The pattern of muscular activity during the arm swing of natural walking. Acta Physiol Scand 63:296, 1965 Copeland SA, Howard RC: Thoraco scapula fusion for fascio-scapulo-humeral dystrophy. I Bone joint Surg 6OB:547-55 1, 1978 DeFreitas V, Vitti M, Furlani I: Electromyographic study of levator scapulae and rhomboideus major muscles in movements of the shoulder and arm. Electromyogr Clin Neurophysiol 20:205, 1980 DiCiovine NM, lobe FW, Pink M, Perry I: An electromyographic analysis of the upper extremity in pitching. I Shoulder

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110.

JOSPT Volume 18 Number 1 July 1993