In Improving Shoulder Function - Part 1, we discussed normal shoulder biomechanics and several causes of shoulder dysfunction. In particular, instability and downward rotation of the scapula are among the most common scapular movement dysfunctions. Part 1 covered a specific strategy to improve stabilization while strengthening the muscles of upward rotation, specifically the serratus anterior, the upper trapezius and lower trapezius. In this article, we will focus on “pushing patterns” as a means of further improving scapular mechanics in order to integrate the shoulder into more functional patterns.
In Part 1, the isolated function of the serratus anterior was discussed. In review, the serratus anterior is a key muscle in maintaining the integrity of the scapula upon the rib cage, in addition to serving as an upward rotator of the scapula. Functionally, however, the role of the serratus anterior is much more extensive. Looking more closely at this muscle’s anatomy will help to clarify the integrated function of the serratus anterior.
Works by Vleeming, Meyers and several other fascial researchers have established and described many direct fascial connections between muscles. For example, one of these muscular connections is the anterior oblique chain. The anterior oblique chain actually begins in the posterior neck with the fascial connections of the splenius capitus/cervicis (A) and rhomboids (see Figure 1). The rhomboids (B) share a fascial connection with the serratus anterior (C) near the medial border of the scapula. Fascially, the serratus anterior blends with the fibers of the external oblique abdominals, which then blend with the internal oblique abdominals and adductors on the contralateral side of the body forming the anterior oblique chain (see Figure 2).
These fascial connections of the anterior oblique chain connect the upper extremity to the contralateral lower extremity. These connections enable the anterior oblique chain to be effective at initiating and decelerating trunk rotation, as seen in throwing or in a golf swing. Therefore, functional conditioning of the upper extremity must take into consideration this integrated function of the upward rotators.
Traditional strengthening of the serratus anterior has required the individual to lie in a supine position and to push the arm up towards the ceiling in a punching-type motion. In individuals who demonstrate over activity and shortness in the pectoralis minor, this causes an anterior tilting of the scapula, which functionally lengthens and inhibits the serratus anterior and the lower trapezius. Therefore, punching-type movements will preferentially strengthen the pectoralis minor and/or major in the presence of serratus anterior inhibition.
The goal of restoring function between the upward rotators and the rest of the kinetic chain lies in proper control and exercise progression. The following exercise progression, beginning with a pushing progression, is extremely effective for activating the scapular stabilizers in their most functional positions (i.e., slightly abducted, upwardly rotated and posteriorly tilted).
Proper loading of the upper extremity and anterior oblique chain begins with push ups. Push ups provide one of the most functional exercises for training the scapular stabilizers and prime movers of the pushing pattern, primarily the pectoralis major/minor, anterior deltoid and triceps. Unfortunately, while many of our clients perform push ups, very few of them are able to stabilize their scapulae properly during the movement. Proper biomechanics during the push up are crucial to ensure optimal stabilization of the scapulae. An elevated surface is utilized for those clients who are unable to perform a higher load. The mechanics remain the same regardless of the level and type of push up performed. The key points are listed below:
- The head, neck, trunk and legs should be in a neutral starting position and remain there during the entire motion.
- The core is activated and maintained throughout the movement.
- The scapulae must be in a neutral position at the starting position and remain there as the trunk is lowered (a minimal amount of retraction is acceptable during the descent).
- The scapulae must remain in a neutral position as the individual pushes up to the starting position (a minimal amount of protraction is acceptable during the ascent).
- The set is over once the individual cannot control the position of the scapula or maintain the spine in a neutral position.
Once the individual demonstrates success on a higher level elevated surface (Figure 3), the level is lowered (Figure 4) until she can perform the ground based push up (Figures 5-6). Again, ensure proper alignment in the loaded position (straight line). The client can be progressed to push ups on a stability ball once she develops strength and endurance in the ground based version (Figures 7-10). The unilateral version may be performed to further challenge the scapulae and core stabilizers once the individual demonstrates optimal control with both feet supported.
Figures 5 & 6
Pushing patterns, one of the fundamental movement patterns, target nearly all primary stabilizer muscles of the scapulae and the core. The cable offers an additional dynamic training component as the upright position trains the lumbo-pelvic-hip to work in unison with the upper extremity. Additionally, increased core stabilization is required to control and move the trunk against the unilateral pull of the cable during the progressions. Additionally, it is the most specific pattern in which to train the anterior oblique chain as discussed above. The key points are listed below:
- The client begins facing away from the cable column in neutral spine and pelvis position.
- The feet are placed in either a parallel (Figures 11-12) or split stance position (Figures 13-14).
- The core is activated and maintained throughout the pattern.
- The trunk, spine and scapulae must be maintained in a neutral position at the start and end of the pattern.
- Without moving the trunk, the cable is pushed until the arm is extended.
- Again, without movement of the trunk, the arm is decelerated to return the arm to the starting position.
- Do not let the elbow extend past the shoulder in individuals with anterior shoulder instability or impingement issues.
- The scapulae must remain flat on the thorax throughout the pattern. A minimal amount of scapular abduction is allowed during the concentric phase, while a minimal amount of scapular adduction is allowed during the eccentric phase of the pattern exercise.
Figures 11 & 12
Figures 13 & 14
Improving shoulder function requires the ability to load the upper extremity optimally while maintaining scapular control. Pushing patterns, including push ups and cable chest presses, are two patterns that develop both scapular stability and integration of the upper extremity to the anterior oblique chain. Part 3 of Improving Shoulder Mechanics will cover pulling patterns as a means of improving scapular control as well as integrating the upper extremity into functional patterns.
- Liebenson, Craig. Rehabilitation of the Spine- 2nd Edition. Lippincott Williams and Wilkins, Baltimore MD, 2007.
- Osar, Evan. Complete Core Conditioning- DVD. Fitness Education Seminars, Chicago, IL 2007.
- Osar, Evan. Complete Rotary Conditioning, Fitness Education Seminars, Course Handouts, Chicago IL, 2007.
- Osar, Evan. Complete Shoulder and Upper Extremity Conditioning, Fitness Education Seminars, Chicago IL, 2005.
- Roskopf, G. Muscle Activation Techniques- Upper Body Function, Course Handouts, Muscle Activation Techniques, Greenwood Village CO, 1999.