Scap squeezes are a common exercise prescribed for patients with neck, shoulder or upper back pain. The intention is to address the patient’s forward, rounded shoulder posture. In a patient with adequate muscle length i.e. no shortening of the pec minor, the exercise will help the patient normalize posture by balancing the front and back muscles of posture.
The most common compensation that I see in patient’s doing this exercise is scapular elevation. That is they hunch their shoulders up as they pull them back. This substitutes one problem for another.
It’s understandable why this error would exist. Most of these individuals will have elevated shoulders as part of their bad posture – these two go together. In someone with hunched shoulders the upper traps are overactive, and stronger, while the lower traps, mid traps and rhomboids are constantly held in a lengthened state, which weakens them. As such, when the person fires their traps to achieve scapular retraction the uppers are stronger and therefore do more. And the shoulders hunch up.
Obviously we’d prefer a pure, smooth scapular retraction without the elevation since that elevation can contribute to shoulder problems and may be a part of the problem we are treating.
So here are some strategies for achieving that, in two different categories:1) motor control – verbal, visual and tactile cues; 2) muscle performance. As with most such things we should expect a combined approach to be more effective than any single strategy.
While working with a patient a while back who was there for neck pain, I said to them, “I don’t want to make you self-conscious about your posture. Wait, actually, I do. I want you do be self-conscious . . .” As we are trying to refine the movement a person makes while doing the scap squeeze exercise we are in part asking them to be more conscious about how they perform the motion. Motor learning is it’s own huge topic that I won’t delve into here, but the principles will be applied.
- Watch themselves in the mirror – I pretty much always have patients do an exercise like this in the mirror. To make sure they understand what they are looking for takes a bit extra for most people. What I found is that most of my patient’s don’t have a sense of scapular depression already, so the instruction I’d give is, “I want you to hunch your shoulders up. Now I want you to move your shoulders the opposite direction.” This got folks into a scapular depression position more effectively than other strategies. The concept is they now have a visual for themselves to watch for in doing the scap squeezes in the mirror. This also helps them do the exercise effectively at home.
- Tactile cue – If the mirror visual isn’t working, or a mirror isn’t available I would put my hands hovering just above their shoulders while they do the exercise and tell them to avoid touching my hands as they the retract their scapulae.
One of the things I don’t do, is tell people where to move their scapulae/shoulder blades. Unlike like their limbs most people don’t seem to have an innate understanding of their shoulder blade, as such an instruction to move it will tend to have the same poor results as an intrinsic cue, even if we might debate whether or not it is one.
The objective here is to supplement our patient’s program with exercises that will preferentially strengthen the lower traps over the upper traps. First, these exercises should not be done in an upright position – the upper traps are active in that position just for postural purposes. So these exercises are done in either a side-lying or prone position
- Prone horizontal ABD+ER
- Prone extension
- Side-lying ER
- Side-lying forward flexion
All the usual guidelines for the prescription of exercise for the purpose of strengthening should be followed, that is, 12RM or higher intensity. In particular the prone extension exercise will tolerate much more weight than the others in most people as the muscles involved are larger.
I recommend progressing the patient to using a bent-over position, as with common dumbbell rowing exercises, for the prone exercises. This brings more postural muscles in to play with the exercise and will be easier for them to do on their own.
I hope you found this useful. As always, let me know if you have any questions!
Cools, A. M., Dewitte, V., Lanszweert, F., Notebaert, D., Roets, A., Soetens, B., … Witvrouw, E. E. (2007). Rehabilitation of Scapular Muscle Balance: Which Exercises to Prescribe? The American Journal of Sports Medicine, 35(10), 1744–1751. https://doi.org/10.1177/0363546507303560