Scap Squeezes: Lower Traps v. Upper Traps

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.

Motor Control

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.

  1. 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.
  2. 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.

Muscle Performance

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

The Exercises

  1. Prone horizontal ABD+ER
  2. Prone extension
  3. Side-lying ER
  4. 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!

References:

https://theprehabguys.com/evidence-based-shoulder-exercises/

Current Concepts in the Scientific and Clinical Rationale Behind Exercises for Glenohumeral and Scapulothoracic Musculature. (2009). Journal of Orthopaedic & Sports Physical Therapy, 39(2), 105–117. https://doi.org/10.2519/jospt.2009.2835

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

Cools, A. M. J., Struyf, F., Mey, K. D., Maenhout, A., Castelein, B., & Cagnie, B. (2014). Rehabilitation of scapular dyskinesis: from the office worker to the elite overhead athlete. Br J Sports Med, 48(8), 692–697. https://doi.org/10.1136/bjsports-2013-092148
jospt.2009.pdf. (n.d.). Retrieved from https://www.jospt.org/doi/pdf/10.2519/jospt.2009.2835?code=jospt-site

Getting Started with Strength Training

(This is an update of a post from my old blog)

This is about getting started with strength training. For those who have little or no experience with the topic.

I firmly believe that just about everybody will benefit from strength training. It has different health benefits from cardio and flexibility training. It is part of the ACSM guidelines for physical activity for adults.

One of the big reasons is that strength training is all about functional activities. I could rename the core exercises of a typical strength training program as:

  • Picking up heavy things
  • Carrying heavy things
  • Carrying heavy things up and down the stairs
  • Pushing something
  • Pulling something
  • Keeping your spine stable

First though, we need to properly define strength training: Strength training is exercises hard enough that you can only do 12 in a row or fewer. Or, with isometric exercises, a position you can only hold for less than 45 seconds. 

Otherwise what you are doing is endurance training. Which is not the same thing.

Primarily, it’s not about which exercises you do, but how heavy. Bodyweight squats are an endurance activity for most folks because they can do 15 or 20 or more. But if you did the exact same exercise while holding weights – enough weight that you could not do more than 12 – then the exercise would be strength training instead.

The basic exercises I recommend here are dumbbell exercises. This is because adjustable dumbbells are cheap, readily available and usable at home; alternately they are commonly available an just about any gym. Dumbbells also address a common cause of hesitation in new folks, the concern about the bar, in barbell exercises. 

The Exercises

  1. Squats – can also be done with the dumbbells held by the side
    • Can also be done with a goblet style hold for lower weights
  2. Split squats 
  3. Straight leg deadlifts
    • Alternate option, easier to do safely – Hip thrust/bridge with weight (you can start this with dumbbells in your lap. You need to put your back up against something sturdy. I push a chair up against the wall).
  4. Bench press – can be done on the floor, a bench isn’t necessary
  5. Bent-over row
  6. Shoulder/overhead press – do this standing not seated 
  7. Pull-ups (a pull-up bar can be gotten that works in almost any apartment and doesn’t require tools to install). Here‘s a primer on doing pull-ups if you can’t yet.
  8. Planks – when you get up to 45 seconds, start adding weight. Put it on the small of your back
  9. Side planks – when you get up to 45 seconds, start adding weight. Put it on your hip
    • Start with the bent knee version if necessary

This set covers every major muscle group in the body and works them in all the major planes of motion. So it is very nearly complete.

The amount of weight you are looking for is something that will develop strength, which means higher weights and lower reps.

Start at 12-15 RM – Repetition Maximum – the number that you can do before you cannot do another with good form.

Start easy on the exercises to develop your form. In the long run good form is much more important that increasing weight quickly.

For each week pick an intensity level. Do all of your exercises at that level. Every 4 weeks you can increase the intensity level.

Intensity levels:

  1. 15 RM – learning the movement
  2. 12 RM – building endurance for the movement
  3. 10 RM – building muscle
  4. 8 RM – building muscle and strength
  5. 6 RM – building strength

I wouldn’t go higher than that without a spotter though.

Do the workout at least twice a week and each session has a rest day in-between another session. So not more than three times per week.

Aim for multiple sets of each exercise. 2-3 sets is a reasonable workout.

But if you only have time to do one of each then start there.

You need to rest between each set to get the most out of it.

  • 12-15RM – rest 60+ sec.
  • 8-12RM – rest 90+ sec.
  • 6-8 RM and heavier – rest 2-4 minutes

You can shorten the rest periods if you alternate exercises between different muscle groups e.g. push/pull or upper/lower. But you’ll still need rest between sets. This sort of plan can be done on “light” days.

For strength training you should also have a “heavy” day where you don’t alternate like this, take appropriate rest periods and do fewer exercises.

Questions? Feel free to ask.

There’s a part II about Putting Together the Program.

Reboot

Welcome to my new blog! Some of you may already be familiar with my previous blog, Fight with All Your Strength. This new blog will reflect my increased training, education and interests. In addition to continuing material on Strength & Conditioning training for HEMA, fencing, martial arts and other combat sports, I will also be writing about:

  • Physical Therapy – these posts will fall into to categories:
    • Patient oriented articles
    • Therapist oriented articles, that is content intended for fellow physical therapists and related professionals
  • General Fitness – while I had a few of these over at my old blog I will get more into this topic here given my expanding work
  • Strength & Conditioning  – for non-athletes and those in sports other than combat sports, as well as strength & conditioning for non-traditional athletics like dance, rock-climbing, circus etc.
  • Nutrition – now part of my formal certifications as a Certified Strength & Conditioning Specialist (CSCS)
  • Science, Skepticism and Science-Based Medicine – my true love/obsession, which underpins everything else I do.  Based in large part on what I’ve learned over at SBM and Neurologica.

Thanks for joining me.