Rotator cuff strength or scapular stability…What comes first?

Posted: January 2, 2013 in Shoulder

Just like a house, which requires a strong foundation to stay supported, so does the glenohumeral joint of the shoulder complex. Although a thorough anatomy review is beyond the scope of this blog, I feel a few key concepts need to be reviewed. The only thing connecting the shoulder complex to the rest of the body is the scapula via the acromioclavicular joint. Some argue that the scapulothoracic complex is a joint but I will argue that is it most definitely not! It’s just a bone (the scapula) sitting on top of the ribs…no joint there. Anyways…

Since the scapula is the only thing connecting the shoulder to the rest of the body, it only stands to reason that it is the foundation from which the shoulder can function optimally. Therefore, I see very little use in training the rotator cuff muscles without first addressing scapular stability AND mobility. Too many clinicians focus on just scapular strengthening exercises without addressing scapular mobility first when they have a client with shoulder pain. For example, if levator scapula is tight, what will it do? It will downwardly rotate the scapula placing it in a disadvantageous position for glenohumeral joint mobility. If pec minor is tight (and who’s isn’t?) what will it do? It will anteriorly tip the scapula lifting the inferior angle off the ribs creating issues for lower fibers of trapezius to aid in upward rotation. Therefore strengthening lower fibers of trap without FIRST addressing pec minor tightness is less than ideal. You will never be able to achieve strength goals until the scapula is sitting flat against the ribcage with the spine of the scapula at around 15 degrees of inclination.

Furthermore, thoracic spine position is critical to scapulohumeral rhythm. An article was just published in the latest JOSPT (December addition) that dealt with the beneficial affects of thoracic spine manipulation on rotator cuff tendinopathy/pain. It only stands to reason that if the upper back is moving better, the scapula can move better, therefore allowing the rotator cuff to act as a humeral head stabilizer instead of a prime mover…which it often has to do in the case of kyphotic postures. So, hypothetically if the thoracic spine is mobile and upright, the tendons of the rotator cuff can “relax” and thus decreasing the inflammatory response due to impingement or overuse.

The beautiful thing about this model is that is applies to so many “shoulder related’ conditions. Thoracic outlet syndrome (TOS) is a function of muscle imbalances and posture. Studies are showing that cervical radiulopathy is also a function of thoracic spine and scapular positioning. Even distal conditions like carpal tunnel syndrome and tennis elbow can be traced back to shoulder positioning (not all the time, but it’s always something a prudent clinician should check).

Conditions such as rotator cuff or long head of biceps tendonosis, upper limb nerve entrapments, and even labral tears can usually be traced back to scapular positioning. But what can we do about this? How do we train the scapula more optimally? Here is the key: STOP doing external rotation exercises for the rotator cuff to fix scapular positioning  I see it all the time and it drives me nuts.

Now I will outline a summery of what I feel needs to be done to addresses many shoulder- related issues:

We all know that we should balance our pushes and pulls, especially with regards to our bench pressing and rowing, right? But what if it’s not so simple a relationship?

In essence, what we’re looking at here is balancing our ability to protract and retract the scapulae. Bench pressing is a horizontal pushing movement that you’d think normally produces protraction (forward movement of the scapula around the ribcage) and trains the muscle that cause protraction, a.k.a. the serratus anterior. The logical opposing movement would be a row of some sort. Balanced, right? Wrong.

Question: What’s the most effective scapular position to maximize bench press performance?

Answer: Retraction and depression

Question: What scapular position is achieved in the contracted phase of a rowing movement?

Answer: Retraction and depression

Balanced? Nope.

Get it? What looks good on the outside, feeds an imbalance on the inside. Serratus anterior becomes ineffective as a protractor, stabilizer, and upward rotator. Then there’s an added bonus. But first a quick anatomy lesson.

Next time you’re cutting on a cadaver (What? Doesn’t everyone?), check out the serratus anterior and the rhomboid. What you’ll find is that because of the fascia that covers everything in the body, they’re essentially the same muscle with the scapula kinda stuck in the middle.

So if the serratus anterior isn’t fully effective at producing an upward rotation force and the rhomboid (a downward rotator) is getting trained with both pushes and pulls, then guess who wins the tug-o-war with the scapula.

Correct! The rhomboids and downward rotation. This means you’re more likely to experience shoulder impingement. (thank you Mike Roberson for that great example!)

It becomes clear that one of the best ways to train the shoulder is…the PUSH-UP!!! This classic exercise is fantastic at activating and strengthening the serratus anterior as an upward rotator of the scapula. It also acts to counteract  the forces of pec minor by flattening the scapula against the rib cage (fighting that anterior tilt a tight pec minor exerts on the scapula).

Lear and Gross determined that push-ups performed with the feet on an elevated surface significantly increased the activation of the serratus anterior compared to traditional push-up variations. If it’s been a while since you performed traditional push-ups, it would be a good idea to start with basic variations, but elevating the feet is a viable progression if your primary goal is improved serratus function.
(J Orthop Sports Phys Ther. 1998 Sep;28(3):146-57.)

Another clutch exercise for optimal shoulder health is the Face-Pull. This exercise works to strengthen the scapular retractors…but the beauty of this exercise is that is does so with the scapula pre-set in an upwardly rotated position.  We must be careful here..too much posterior deltoid activity is no good…we want pure scapular retraction occurring with minimal humeral head elevation.

Another not so popular exercise that is often forgotten for shoulder health in the Standing Straight-arm pulldown. I love this exercise because it is dead easy to preform and coaching for it is a breeze. Very little that can go wrong here. This exercise is fantastic because it teaches the latissmus dorsi muscle to work to depress the humeral head in the glenoid without activating the deltoid. This will prevent excessive humeral head elevation with overhead reaching…a common source of pain in shoulder pathology patients.


Besides exercise, I will ALWAYS employ manual therapy to help with scapular positioning. Here is what I do:

Pec Minor soft tissue release (I would say ART but I’m not allowed…it’s like $2500 for a weekend ART course…are they serious?!?!) I digress… I pin the muscle just at its origin on the coricoid processes and passively or actively flex the arm in the plain of the scapula to release this muscle. I then do manual stretching to aid in loosening it up.

Levator scapula/Upper trap stretching and soft tissue release

Passive side lying scapular mobs into elevation, depression, upward and downward rotation

Thoracic spine manipulation to aid in upper back mobility

(Not exactly how I do it, but you get the idea…you want more of a superior directed force as opposed to a straight anterior to posterior force)

So how do you make a rotator cuff happy?

1) Address upper back posture.

2) Maintain optimal balance of the muscles around the scapulae and the shoulder joint.

3) Then addresses rotator cuff muscle strength AND endurance (which is an entire post in itself!)

Happy new year!!

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Comments
  1. Great as always Jesse. I’ll be sure to share!

  2. jessephysio says:

    Thanks Erson!! Really appreciated. Happy new year bud!

  3. Mike Reinold says:

    Good one Jesse, I like your integrated approach to work the scap, cuff, t-spine, and manual therapy. Need them all. I would also add manual therapy for the subscapularis, as this also has many of the same issues as the pec minor like you mentioned.

    Keep up the great work, thanks for sharing your expertise!

    • Greg Lehman says:

      Hi Jesse,

      This might sound dumb but I don’t quite see why you don’t want to train the rotator cuff while doing all the other work.

      If I stick within your framework of wishing to train the serratus anterior and the rhomboids/lower traps (with the facepull) why can’t you incorporate basic rotator cuff exercises? Scaption trains the supraspinatus while also being an excellent serratus anterior exercise. It has comparable if not more muscle activity than a pushup or push up plus.

      Simple external rotation at 0 degrees of abduction (eg. with a band) trains the posterior rotator cuff but also trains the lower fibres of the trapezius which help in upward rotation of the scap as well as posterior tilt. If this exercise created some impingement of sensitized neural tissue with the subsequent nociception the patient would probably know it and avoid it.

      All the exercises that you recommend are great but they also have high amounts of rotator cuff activation.

      By the way, I think your treatment for this is fine and will get people better. I just don’t see whats so bad about training the cuff. Sometimes you will find if you do simple rotator cuff work that patients will have immediate improvements in range of motion in other planes of movement (e.g flexion)

      thanks for posting.

      Greg

    • poulhaacker says:

      Personally with my very limited experience compared to the giants writing in these comments, I have oftentimes seen great benefits from working on the supscap with active release technique. Sometimes replicating the pain location and nature while working on the tissue, and relieving it immediately when pressure on the affected areas is taken of.

  4. jessephysio says:

    Hi Greg, thanks for reading!
    My concern is one of experience to date. I have seen an influx of shoulder pain clients who have been given the classic side lying ER and IR at 0 degrees abd and other cuff exercises but when I look at them I see a lot of scapular dyskinesis, winging, anterior tipping and or downward rotation. I feel that training a cuff (which attaches on the scapula) while the scapula itself is unstable is just not as effective as first taking the time to do the stuff I mentioned for the blade and then working the cuff with the exercises you mentioned. Don’t get me wrong, I give cuff ER, IR, scaption, perturbation work exercises a lot. It’s like shooting a cannon from a sail boat if you try to train the cuff without working on the scapula first (in my opinion).

    Also, I don’t like giving my clients more than 2-3 exercises to work on at a time as I feel adherence goes way down after 3. So for my money, scapular stability trumps cuff strength at the onset.

    I was however unaware that side lying ER works the lower traps! Great to know. Any reference for that? If you disagree with me please tell me…i’m always open to being proven “wrong”…it’s partly why I write this blog :)

    Keep up the great work on your blog. It’s amazing what you publish for free!

    When are we grabbing that lunch?

  5. greglehman says:

    Hi Jesse,

    Ann Cools has published the emg research. Here is a link to a summary. http://www.thebodymechanic.ca/2011/01/25/shoulder-rehabilitation-minimizing-the-upper-trapezius-to-serratus-anterior-ratio/ you will also get a lot of activity with band ERs at 0 and 90 degrees or do prone Ws or Ts. All of these work the cuff and the scap muscles, they are a team. You can also check out the great EMG review by Rafael Escamilla a few years ago.

    My point here is that you cant work the cuff in isolation. You will be working the muscles of the scap so the rowboat analogy falls apart. I think you also know that callng the scap unstable is a little catastrophic. What does an unstable scap even mean? A little bit of winging? Its these debates about biomechanics (i.e. we can argue all day about different ideas of biomechanics with different research papers that show good results) that suggest to me that the biomechanics have little to do with pain.

    If you have a patient with inferior scap border prominence, some dyskinesis with no pain are you going to advise them that this must be corrected before they can do bench pressing, seated rows, overhead activity? They will do corrective work forever and may see no change. The link between these normal variations in scapular position/kinematics and future pain/injury is sparse (see J Lewis) and the link between improvements in shoulder pain and changes in posture is also weak (despite an exercise program designed to change these variables).

    Sorry, jesse this is a big issue. I think that you are training the cuff with the exercises you recommend and i think that the biomech data suggests that you are trainng the scap stabilizers while doing cuff work. It doesnt matter in terms of clinical efficacy. Its all a lot simpler than we think.

    And i dont disagree with you that this helps your patients. I just think that your solution is overly complicated and a tad rigid even if i only debate it with biomechanics. but your observation that you get better results with different exercises is interesting. If i can prove to you that it is not biomechanics (e.g. My point about the cuff training also being scap training) than this is where you have to be open to another mechanism for your clinical results.

    Lunch soon, email me

    Greg

    • poulhaacker says:

      Hi Jesse, love your post! Shared it on my blog, but i am sure I won’t be able to drive the traffic here, Erson can provide. You really have a gift for explaining things in a very clear manner. FOr instance the relationship of the rhomboid and serratus. Great job!
      One minor disagreement. I have attenden Active release technique upper and lower and intend to continue learing the techniques. Have had awesome success with releasing the rotator cuff muscles, rhomboids, levator, pec minor for classical supraspinatus impingement. I don’t have much experience compared to you, and you know a lot of very interesting techniques. I still encourage you to investigate it further. You might be able to improve your already impressive skill set and clinical expertise.
      Greeting from cold Denmark, Poul Haacker

    • poulhaacker says:

      Thx greg, Wonderful info!

    • jessephysio says:

      HI Greg,

      Thanks again for sharing your expertise. I don’t believe I stated in my blog that you can only work any particular muscle or group of muscles in isolation. My point is that I agree with you, but I still believe we have to have some rational evidence/biomechanical plausibility for choosing the exercises we do. I mean, yes all shoulder movements regardless will work the cuff to some degree. But aren’t there some that work it better than others? Inversely, aren’t there some exercises with target the serratus/lower traps etc to a higher degree than the cuff? Based on the EMG studies you provided there are some exercises that are better than others for the goal of the individual client. Following your line of thought that all shoulder exercises work the cuff and scapular stabilizers would indicate to me that you basically tell your shoulder pain clients to just move their arms around in various directions because you are working all the muscles in the area regardless of what specific exercise you do. I just think there should be a rational progression of exercises…regardless of the are of the body we are treating…I’m sure you would agree.

      You asked if I had a patient with scapular positioning issues would I let them do overhead work If they had no pain.I really wouldn’t stop them. However, that’s not what I’m discussing. Yes, some clients have scapular dyskinesis without pain while doing over head activity. Does that mean that you can’t attribute some patients shoulder pain to scapular positioning faults? Just as we can’t always attribute a disc bulge on MRI to someone’s lower back pain, it doesn’t mean that the bulge can’t be a source of nociception in someone else. See what I’m saying? I also like to simply things…if I see something that could be considered a biomechanical fault and the pain they present with makes sense in terms of said biomechanical fault, I don’t discount it as being a contributing factor in their pain..ie. if someone has a depressed shoulder blade and their complaint is pain with overhead movement at 90 degrees… their depressed shoulder blade just might be the reason they have pain. No? If I manually correct their scapula positioning while doing the aggravating movement and their pain abolishes I can be reasonably sure that correcting the faulty positioning will ease their pain.While I agree that labelling someone with scapular instability maybe a bit over the top, I don’t discount scapular positioning/movement from being a factor in a clients shoulder pain.

      Looking forward to your reply Greg…I’m sure I’ve butchered your thought processes on this topic and possibly even assumed some things! If so I apologize!

      I will email you this week

  6. thank you some real good information

  7. Greg Lehman says:

    Jesse,

    It looks like you are coming around :). Your initial piece said:

    ” see very little use in training the rotator cuff muscles without first addressing scapular stability AND mobility”.

    My points were twofold:

    1. When you train the rotator cuff you are training the scapulothoracic muscles. When you train the scapulothoracic region you will be training the cuff. There is no point in making blanket statements that say you HAVE to train the scap thoracic first before training the cuff as this impossible.

    2. We need to question what it is we think we are doing when rehabilitating someone in pain. Initially, you seemed very certain that if you had scap instability (e.g. firing a canon from a rowboat) you were having pain. You are now correctly suggesting that sometimes the mechanics (e.g scapular positional faults, dyskinesis) do not matter sometimes. Absolutely. This was my point. What we have a lot of research that these biomechanical faults (e.g depressed shoulder blade) does not change even when the rehab program tries to change these positions and even after the pain has been resolved.

    As for manually correcting the scapular position and getting changes in pain: of course we can put our hands on someone and have them move and they feel less pain. This does not mean that you actually “manually corrected” any position. You think you did, you definitely did something, but don’t assume that this was something mechanical. Lots of assumptions in there and these can all be explained by other mechanisms and what we know about pain science.

    You recognizing that not all “postural faults” equal pain tell me you are open to this. Also allowing to a client to train a bench press even with scapular “faults” tells me you don’t think it matters sometimes as well.

    As for me having my patients just wave their arms around. Yes, I do do this. And I just found out recently that David Butler does the same thing. Why would you not wave their arms around. You train the whole shoulder region in a pain free manner, maybe you can add some weight, change speeds, change positions in relation to gravity, add a body blade or add a cable. The arm is built to be waived around. Do I explain my treatments are changing biomechanics? No. Do I think that their biomechanics might change with pain resolution, Yes, sometimes. But it is not necessary because I don’t think the biomechanical changes cause the changes in pain production. It can be the other way around or not at all.

    Your looking for a biomechanical platform to justify your exercise prescription. It does not have to be so rigid. We don’t need so many rules.

    Get the patient moving, build on this with a variety of movements, don’t scare them by telling them their scap is unstable and they can’t do rotator cuff work until their scap is stable or moving again.

    Anyways, I am working on a whole series of posts on corrective exercise that I hope can better explain this.

    Greg

  8. [...] Rotator cuff strength or scapular stability…What comes first? [...]

  9. [...] Da jeg skrev min sidste blogpost om skulder rehab, fik jeg en lang række ønsker om at jeg skrev noget lignende omkring musklerne der stabiliserer skulderbladet. Jesse Awenus en dygtig canadisk fys skriver her om hans tilgang til skulder behandling. [...]

  10. [...] Rotator Cuff Strength or Scapular Stability…What comes first? – Great post from Jesse Awenus. [...]

  11. [...] Rotator cuff strength or scapular stability…What comes first? (jessephysio.wordpress.com) [...]

  12. [...] Rotator cuff strength or scapular stability…What comes first? (jessephysio.wordpress.com) [...]

  13. Hi Jesse

    Really like your blog and the ideas that you have put forward here.

    The debate between yourself and Greg is also incredibly valuable to the blog and provides sound reasoning for all the suggested rehab principles for the shoulder.

    We will never stop our rugby players doing their bench press!! But I agree with Greg in that integrating drills like the press up plus on unstable surface, TRX drills (W’s & T’s) and cable work through range for internal and external rotation will recruit rott cuff as well as improve scapula stability.

    I like to promote a preferred posture at the scapula / thoracic spine for my players (they love that hunched over massive traps look!!). However, I don’t feel that you can recruit purely on verbal command, the ‘corrective’ exercises should be functional with plenty of visual feedback to drive this.

    My approach, similar to your suggested exercises is to work as ‘functionally’ as possible to the task (for my guys rugby 7s – coping with load and repeated contact). My focus for these athletes is on their ability to manage load during weight bearing and also through range in a variety of positions…very basic and simple principles of working them hard with drills that relate to their sport.

    Great blog and great debate.

    Kind regards

    Dan

  14. Glynda says:

    Can you help me I am stuck between rock & a hard place . 2012 I was knocked of my pushie by a car landed on shoulder poped it out & tore the insparspinous & inferspinorus he anchored them back with 3 bone anchors . Having suffered constant pain under scapula from the very first night of the op . Done nerve test is ok . Have a lot of muscle wastage in the inferspinorus muscle nearly all is bone now . They now want to do a release of the scapula , I can’t move my arm backwards & even out to the side it won’t go back . Is there any other way then the knife . Please could you please answer this . I am at my wits end my karate is suffering as much as me .

    • jessephysio says:

      Hi Glynda,

      I’m so sorry to hear about the issues your facing. I can imagine how frustrated you must be. Without assessing you it makes it impossible for me to give you any recommendations on treatment. Can I ask where about you are located? I maybe able to refer to you a trusted colleague to provide quality care for you. I’m not sure what a scapula release is…can you give me more information about this? Were you diagnosed with frozen shoulder? There are many possibilities for why you have the pain you do. The key is to find someone who knows what they’re doing to help you.

      Let me know,
      Jesse

  15. Glynda says:

    I forgot as well my my right shoulder has droped since the op to . I have 100% outward rotation of my left arm but I only have 65% of my right arm after 13 mths & I’ve just about had a bloody gut full . I want my bloody arm back .

  16. sydney says:

    Really made a very long argument/blog shorthand to the point. I like the comment too on anti-extensors, may have to borrow that term!
    adhesive capsulitis treatment

  17. Ryan says:

    Would this help with bursitis?

  18. gbernardwande; says:

    Good stuff.
    glad you addressed the “over-external-rotationization” of the planet as it drives me nuts too!

    • gbernardwandel says:

      gbernardwandel….not ;

    • Glynda says:

      I had a chronic tear in rotator cuff due to a fall . Because they retracted to far they were stretched & anchored with 3 bone anchors thus pulling on the muscle’s & nerves leading to chronic pain , muscle wastage & a unstable scapula . The other muscles in my back have been working over time due to this as well as neck muscle & these are pulling on the little muscles in my ear giving me blocked ear syndrom . I had my operation 2years ago on may 22 , I sometimes rue the day I had the opp .

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  20. Brian Noyes says:

    Hello my name is Brian Noyes, about a year ago I was at the skatepark and fell on my outstretched left arm and dislocated my shoulder, I put it back in place and went on with my life with no pain occurring other then when I hung on it or putting my arm behind my head when I was sleeping. About 4 months ago I fell again this time directly to my back and dislocated my shoulder again. This time though I cause myself to have a winging scapula and a very weak arm. I have full range of motion although there is always pain especially doing overhead lifting. My arm is very weak compared to what it used to be (about 50%) My deltoid muscles are barely there and are diminishing more and more. I have been getting help for the past month with physical thereapy but it doesn’t seem like its doing much. I live in Orlando florida and was wondering if there is anyone you know around here that knows what there doing and can really help me, or if you can give me some advice your self. It has been a very depressing 4 months and im only 20 years old and I feel like im going to be crippled for life. PLease Help!!!

    • Glynda says:

      Hi Brian I am from Queensland Austrila go find your self a good orthopaedic surgeon & see what they say . I was hit by a car while I was out riding my push bike & tore my rotar cuff off the bone , with in a month of waiting to see someone ihad muscle deteration as well . Even after a opp my arm has never been the same . But good luck with yours .

      • Brian Noyes says:

        Thanks for the reply! I am going to see an orthopedic surgeon hopefully within the next month. (Insurance is really annoying). My physical therapists does not see any reason why I would need physical therapy but when I asked her if she has aver delt with a case like mine and she said no. Hopefully I can get some help in the near future and return to my active lifestyle!

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