Brian Schiff’s Blog

It is no secret that proper scapula alignment and muscle activation makes for a healthy shoulder.  There are many forms of dysfunction that may be present.

Generally speaking problems revolve around muscular tightness/weakness and faulty movement patterns.  The term “SICK” scapula is often used and refers to Scapula Inferior Coracoid Dyskinesis.  Common examples of a “sick”  scapula include:

• Type I – Inferior border prominence.  This is typically related to tightness in the pec minor and weakness in the lower trapezius.  Keep in mind the upper trapezius will naturally dominate the lower trap in the force couple with the serratus anterior for upward rotation.  You may also see increased thoracic kyphosis which will inhibit the normal resting position of the scapula.
• Type II – Medial border prominence.  In this case the scapula is internally rotated or protracted and there is liekly weakness present in the rhomboids and middle trapezius.  The serratus anterior may also likely be weak with evidence of scapular winging.  This position places the humerus in relative internal rotation and increases risk of impingement with arm elevation.
• Type III – Superior border presence.  Here the scapula appears elevated in the face of an overactive upper trap and/or levator scapulae.  With active arm elevation, you may notice excessive shrugging or superior humeral head migration in light of the imbalance.  Again, the lower trapezius is probably weak and being overpowered.

Click here for a great graphic display from the Journal of the American Academy of Orthopaedic Surgeons of how the scapular muscles work collectively as a force couple to promote optimal movement in the shoulder.

In many of the throwers and overhead athletes I see in the clinic, they often exhibit either medial border prominence of inferior border prominence.   Additionally, I frequently observe GIRD (glenohumeral internal rotation deficit) values of 20 degrees or higher in those patients who come in with symptomatic shoulders (rotator cuff and/or labral issues).  What does this mean?

Well, in a nutshell, it means addressing posterior capsule tightness in the throwing shoulder is important for avoiding internal impingement and SLAP tears.  Tightness (or too much GIRD) can increase the load/tension in the late cocking phase of throwing thereby contributing to friction between the cuff and labrum, as well as excessive torsion on the proximal biceps tendon.  Any excessive humeral head migration with repetitive throwing is a recipe for injury over time.

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Dysfunctional movement is common with shoulder pain and impingement.  One dysfunction you may encounter is a downwardly rotated scapula. If upward rotation is limited, a client will display excessive shoulder flexion above 90 degrees when the humerus is in maximal internal rotation.  Typically, a person will have minimal flexion beyond 90 degrees if the scapula is moving properly.

Upward rotation of the scapula is the result of a force couple between the upper and lower trap along with the serratus anterior.  If any of these muscles are weak, rotation can be limited and overpowered by the rhomboids and levator scapulae muscles (both downward rotators).  This pattern of muscle dominance is common.

Additionally, tightness in the rhomboids, levator scapulae, pec minor or latissimus can also restrict normal mobility.  It is probably safe to assume stretching of the chest and lats would be helpful, but it is critical to encourage the proper muscle firing patterns in the traps and serratus anterior as well.

Below is a video demonstrating wall slide shrugs.  The shrug should be done at or above 90 degrees.  You can perform reps at multiple angles or move to end range and perform a series there.

Application:  The exercise is designed to encourage upward rotation in a more functional manner as opposed to traditional shrugs with the arms at the side.  While I am not opposed to traditional shrugs with little or no weight for basic elevation, this position generally tends to activate the rhomboids and levator scapulae which is not desired given their natural dominance pattern.

The wall slide shrugs should not create any pain or discomfort.  However, they may feel awkward particularly if the client has a faulty muscle activation pattern.  As muscle tightness resolves and strength improves, clients should gain more mobility and optimal shoulder function.

By far the most common problem I see in the clinic is shoulder pain. Most of the time it is related to overuse, rotator cuff tendonitis/impingement and labral tears. Because we are geared more toward sports rehab, I also treat a lot of overhead athletes (baseball players, volleyball players and swimmers).

A common thing I will see in those suffering from impingement or rotator cuff pain is scapular winging. Most of the time the muscle is simply deficient in strength/endurance and it along with the lower trap become overpowered by the upper trap, levator or even the rhomboids. Shortened scapulohumeral muscles, poor posture and pec tightness can also impact winging.

There are many traditional exercises such as serratus punches, push-ups with a plus, and serratus plank push-ups to name a few, but I wanted to include a closed chain exercise that can be very effective for facilitating proper activation of the serratus – quadruped rocking.

In the video, I show it with both hands fixed on the floor progressing to one hand (on the involved side). The key is quality of movement throughout. After you check out the video, be sure to scroll down and click the link to a full column I wrote for PFP magazine on this exercise as it further explains the technique and application.

Click here to read the online column for PFP Magazine.

In most gyms and training circles, people are performing bench press or push-up exercises.  There is no doubt in my mind that repetitive heavy full range bench press causes many of the labral and cuff injuries among males I have seen over the years These injuries are often the attritional type – developing over many months and years.

What about push-ups?  Is the force development pattern the same?  Are they safer?  Honestly, I believe in keeping the elbow at a point at which it does not drop below the plane of the body (bench press) or move above the body (push-up).  Essentially that means keeping to a 90 degree angle or less.  Why?  Well, regardless of load, I feel the real risk is not so much in the motion itself but the very repetitive manner in which it occurs with external loads, often lending itself to acquired anterior shoulder laxity, strain on the proximal biceps anchor (think SLAP lesions) and secondary shoulder impingement.  The picture below hurts my shoulders just looking at it, and over time this technique will hurt your shoulders too.

But, I say all that to set up today’s post.  In a recent article in the February edition of the Journal of Strength & Conditioning Research, David Suprak et al. looked at the effect of position on the % of body mass supported during traditional and modified push-ups.

The study looked at 4 static positions in 28 males (about 34 years old) who were highly trained and members of the special forces or SWAT team (the up and down position for regular and modified push-ups) to determine the change in body mass (BM) supported by the upper body in different ranges of motion.  The down positions studied were at approximately 90 degrees (the lowest depth I safely recommend) and all holds were performed for 6 seconds.

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