Kinesiologic For Activation Scapulothoracic Trapezius PDF

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1 Brazilian Journal of Physical Therapy 2019;xxx(xx):xxx---xxx
2
3 Brazilian Journal of
Physical Therapy
https://www.journals.elsevier.com/brazilian-journal-of-physical-therapy
MASTERCLASS
4 Kinesiologic considerations for targeting activation of

5 scapulothoracic muscles --- part 2: trapezius
6 Q1 Paula R. Camargo a,∗ , Donald A. Neumann b
a
7 Laboratory of Analysis and Intervention of the Shoulder Complex, Department of Physical Therapy,
8 Universidade Federal de São Carlos, São Carlos, São Paulo, Brazil
b
9 Department of Physical Therapy, Marquette University, Milwaukee, WI, USA
10 Received 27 December 2018; accepted 17 January 2019
11 KEYWORDS Abstract
12 Physical therapy; Background: The trapezius is an extensive muscle subdivided into upper, middle, and lower
13 Scapular dyskinesis; parts. This muscle is a dominant stabilizer of the scapula, normally operating synergistically with
14 Scapulothoracic other scapular muscles, most notably the serratus anterior. Altered activation, poor control,
15 joint; or reduced strength of the different parts of the trapezius have been linked with abnormal
16 Shoulder scapular movements, often associated with pain. Several exercises have been designed and
17 rehabilitation; studied that specifically target the different parts of the trapezius, with the goal of developing
18 Trapezius exercises exercises that optimize scapular position and scapulohumeral rhythm that reduce pain and
19 increase function.
20 Methods: This paper describes the anatomy, kinesiology, and pathokinesiology of the trapezius
21 as well as exercises that selectively target the activation of the different parts of this complex
22 muscle.
23 Conclusions: This review provides the anatomy and kinesiology of the trapezius muscle with the
24 underlying intention of understanding how this muscle contributes to the normal mechanics of
25 the scapula as well as the entire shoulder region. This paper can guide the clinician with planning
26 exercises that specifically target the different parts of the trapezius. It is recommended that
27 this paper be read as a companion to another paper: Kinesiologic considerations for targeting
28 activation of scapulothoracic muscles --- part 1: serratus anterior.
29 © 2019 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Published by Elsevier
30 Editora Ltda. All rights reserved.
31
32 33
∗ Corresponding author at: Laboratory of Analysis and Intervention of the Shoulder Complex, Department of Physical Therapy, Universidade
Federal de São Carlos, Rodovia Washington Luis km, 235, 13565-905 São Carlos, São Paulo, Brazil.
E-mail: prcamargo@ufscar.br (P.R. Camargo).
https://doi.org/10.1016/j.bjpt.2019.01.011
1413-3555/© 2019 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Published by Elsevier Editora Ltda. All rights reserved.
Please cite this article in press as: Camargo PR, Neumann DA. Kinesiologic considerations for targeting activation
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scapulothoracic muscles --- part 2: trapezius. Braz J Phys Ther. 2019, https://doi.org/10.1016/j.bjpt.2019.01.011
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2 P.R. Camargo, D.A. Neumann
34 Introduction
35 Q2 Scapular position, stability, and control play an important

36 role in the strength and integrity of shoulder movement.
37 These elements are highly dependent on the interplay of
38 several scapulothoracic muscles. The serratus anterior and
39 trapezius constitute the main force couple acting at the
Upper trapezius
40 scapula. Weakness or improper activation of the scapular
41 stabilizers can alter scapular positioning and mechanics.
42 This paper is part 2 of a companion paper.1 Part 1 reported
43 kinesiologic and therapeutic considerations for targeting the
44 activation of the serratus anterior. This review paper will M
take a similar approach to describe the therapeutic applica- tra iddl
45 pe e
ziu
46 tions to the trapezius muscle. As a background, this review s
47 will also present the anatomy, kinesiology, and pathokinesi-
48 ology of this complex muscle. Posterior
deltoid
49 Anatomic considerations
trap
Low ius
50 The trapezius is the most visually prominent and superficial
ez
er
51 of all scapulothoracic muscles (Fig. 1). This extensive mus-
52 cle is subdivided into upper, middle and lower parts.2 The
53 upper trapezius arises from the occiput, superior nuchal lig-
54 ament, and spinous processes from vertebra as low as C6,
55 and runs near vertically to attach to the posterior border of
56 the distal third of the clavicle. The middle and lower trapez-
57 ius originate from the spinous processes of C7 through T12.
58 The horizontally running middle trapezius attaches to the
59 acromion and spine of the scapula, while the lower trapez-
60 ius runs obliquely superiorly to attach to the medial base of
61 the scapular spine. As noted in Fig. 1, the different parts
62 of the trapezius have distinctly different fiber directions,
63 hence explaining the muscle’s multiple actions.
64 The trapezius receives its primary motor innervation from Figure 1 The 3 parts of the trapezius muscle. The posterior
65 the spinal accessory nerve (cranial nerve XI).2 Sensory inner- deltoid is also illustrated. Note that the red arrow shows the
66 vation is received from branches of nerve roots C2, C3 and line of action of the upper trapezius muscle
67 C4. The spinal accessory nerve courses obliquely inferiorly Reproduced with permission from Neumann DA, Kinesiology of
68 between the posterior border of the mid portion of the the Musculoskeletal System: Foundations for Rehabilitation, 3rd
69 sternocleidomastoid and anterior border of upper trapez- ed, Elsevier, 2017.
70 ius. Injury to the relatively vulnerable nerve may cause
71 paralysis or marked weakness of both the trapezius and contralaterally rotates the thoracic spine; with the thoracic 90
72 sternocleidomastoid muscles. Isolated trapezius weakness spine held fixed, middle trapezius retracts and externally 91
73 typically results in a ‘‘drooping’’ of the shoulder girdle rotates (within the horizontal plane) the scapula.6 As a final 92
74 (i.e., depressed and protracted scapula and clavicle), cou- example based on this topic, with the scapula fixed, lower 93
75 pled with excessive downward rotation of the scapula.3,4 trapezius laterally flexes the lower thoracic spine; with 94
76 The shoulder girdle loses its essential source of muscular the spine held fixed, lower trapezius externally rotates the 95
77 stabilization, potentially leading to subluxation of the gleno- scapula and depresses the shoulder girdle, and (with assis- 96
78 humeral and sternoclavicular joints if the condition remains tance of serratus anterior and upper trapezius) upwardly 97
79 chronic.5 rotates the scapula.7,8 98
The trapezius and serratus anterior act synergistically to 99

80 Functional considerations produce many actions of the scapula or clavicle (Fig. 2), typ- 100
ically associated with flexion or abduction of the shoulder. 101
81 Ultimately, the specific movements caused by contraction of From a broad functional perspective, the trapezius may be 102
82 the trapezius are based on which attachment points of the considered a dominant stabilizer of the scapula, while the 103
83 muscle are held most fixed (rigid). For example, with a rel- serratus anterior a dominant mover of the scapula, although 104
84 atively fixed craniocervical region, upper trapezius elevates considerable overlap exists in these generalized functions. 105
85 and retracts the clavicle; with a relatively fixed shoulder As the arm is elevated during abduction or flexion, the 106
86 girdle, upper trapezius contributes to craniocervical exten- scapula upwardly rotates, internally/externally rotates, and 107
87 sion and lateral flexion. Other similar examples can be posteriorly tilts.9---13 By far, upward rotation is the most obvi- 108
88 applied to middle and lower trapezius. With the scapula ous and extensive motion, which can be verified by palpating 109
89 held relatively fixed, middle trapezius laterally flexes and the path of movement of the inferior angle of the scapula. 110
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Trapezius muscle 3
A. Anterior view D. Posterior view
clavicle
elevation
UT
scupula
upward rotation
SA
B. Superior view
LT
clavicle
retraction UT
E. Lateral view
C. Superior view scupula

posterior tilt
LT/Mt
scapula
external rotation scapula
external rotation
scupula
posterior tilt
SA
SA
LT
Figure 2 Lines of action of selected scapulothoracic muscles are depicted by red large straight arrows (UT: upper trapezius,
MT: middle trapezius, LT: lower trapezius, SA: serratus anterior). The muscles are shown contributing to clavicular elevation (A),
clavicular retraction (B), scapular external rotation (C), scapular upward rotation (D), and scapular posterior tilt (E) during shoulder
flexion. Internal moment arms for muscles are shown as a solid line from the axis of rotation to the line of action of each muscle.
Dashed lines indicate a right-angle intersection between muscle’s line of action and its moment arm. Note two axes of rotation:
the sternoclavicular axis, located near the manubrium, and the acromioclavicular axis, located near the acromion.
111 Other more subtle accessory motions refine the position protraction and retraction, respectively. Although variable, 117
112 of the scapula as it upwardly rotates. Simultaneous with the scapula tends to internally rotate slightly during flexion 118
113 the upward rotation, for example, the scapula internally or to project the glenoid fossa more anteriorly; slight exter- 119
114 externally rotates, depending of the plane of arm elevation nal rotation typically occurs at the end range of flexion. 120
115 and portion of the range of motion.11 Internal and external Abduction closer to the frontal plane, however, is typi- 121
116 rotations of the scapula are also commonly referred as to cally associated with slight external rotation of the scapula, 122
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Figure 3 Manual muscle test of strength of the upper trapezius (A), middle trapezius (B) and lower trapezius (C).
123 which projects the glenoid fossa closer toward the frontal Although isolated paralysis of the upper trapezius is rare, 171
124 plane for better congruency with the abducting humerus. such a condition results in a loss of support of the shoul- 172
125 The position of the upwardly rotating scapula is further der girdle, along with excessive scapular internal rotation or 173
126 refined by a posterior tilting motion. This relatively consis- protraction. Upward rotation of the scapula is typically only 174
127 tent motion takes the acromion posteriorly, away from the minimally impaired, compensated primary by an innervated 175
128 advancing humeral head. This is likely a mechanical strategy serratus anterior. 176
129 that favors an increase in the subacromial space, thereby

130 reducing likelihood of excessive contact between humeral
131 head and acromion or other soft tissues. Middle and lower trapezius 177
132 Acting in concert with the serratus anterior, forces pro-

133 duced by each of the three parts of the trapezius are The middle and lower trapezius produce scapular retraction 178
134 essential to the fluid motion of the scapulothoracic joint by a direct translational pull on the bone. These muscles 179
135 and therefore the entire shoulder complex. Scapulothoracic also externally rotate the scapula via a torque produced 180
136 motion and/or stability serves as the basis for all shoulder across the acromioclavicular joint. The external rotation 181
137 motions, not just abduction and flexion which are empha- force produced by the middle and lower trapezius is par- 182
138 sized throughout this paper. ticularly important during shoulder abduction or flexion, 183
as these muscles must offset the strong lateral translation 184
(protraction) and internal rotation force produced by simul- 185
139 Upper trapezius taneous activation of the serratus anterior7 (Fig. 2C). The 186
lower trapezius along with the serratus anterior are the pri- 187
140 Because the upper trapezius attaches distally only to clavi- mary upward rotators of the scapula (Fig. 2D), especially 188
141 cle, most of its influence on scapulothoracic mobility is due during the early and middle range of shoulder abduction.14 189
142 to forces applied directly to this bone. Contraction of the The lower trapezius is most aligned to upwardly rotate the 190
143 upper trapezius creates a strong elevation and a retraction scapula during abduction more than during flexion. Although 191
144 pull on the clavicle at the sternoclavicular joint7,8,14 (Fig. 2A the middle and lower trapezius may partially assist with 192
145 and B). The moment arm of the upper trapezius for these posterior tilting of the scapula, the primary muscle for this 193
146 actions relative to the sternoclavicular joint is large, con- action by far is the serratus anterior8,14 (Fig. 2E). 194
147 ducive for effective torque production and support of the

148 entire upper limb.
149 Partially because the upper trapezius attaches distally Classic manual muscle test of the strength of 195
150 to the clavicle (and not the scapula), its ability to directly the trapezius 196
151 control the upward rotation of the scapula is relatively min-

152 imal and thus dependent on other muscles.7 Nevertheless, Manual muscle testing is utilized extensively in the clinic 197
153 by attaching to the clavicle, the upper trapezius exerts a to determine the strength and control of the trapezius. 198
154 significant influence on other kinematics across the shoul- These tests help clinicians determine the most appropri- 199
155 der girdle. Specifically, the forces exerted by the upper ate therapeutic approach to improve muscle performance 200
156 trapezius on the clavicle are strongly linked to the natural during the rehabilitation program. The following tests are 201
157 kinematic coupling that exists between the sternoclavic- based primarily on the classic manual muscles tests origi- 202
158 ular and scapulothoracic joints: elevation of the clavicle nally described by Kendall et al.6 203
159 contributes about 75% of scapular anterior tilt and only One common way to test the strength of the upper 204
160 25% of upward rotation of the scapula.15 Clavicular retrac- trapezius is depicted in Fig. 3A. From a starting position 205
161 tion contributes to 100% of scapular external rotation.15 As of slight craniocervical ipsilateral lateral flexion, manual 206
162 such, isolated contraction of the upper trapezius contributes resistance is simultaneously applied against craniocervical 207
163 modestly to upward rotation, but significantly to external extension-and-lateral flexion and elevation of the scapula. 208
164 rotation of the scapula.14 Although Neumann has described A weakened trapezius typically results in the lack of ability 209
165 the upper trapezius has part of a classic force-couple for to bring the acromion of the scapula toward the head. 210
166 upward rotation of the scapula,5 this function is secondary The strength of the middle trapezius may be tested 211
167 and indirect, and only possible with simultaneous activation with subject prone and shoulder externally rotated and 212
168 of the lower trapezius and serratus anterior. abducted near 90◦ . Resistance is applied on the arm against 213
169 Understanding the effects of a paralysis of a given mus- the motion of shoulder horizontal abduction6 (Fig. 3B). 214
170 cle can help explain a muscle’s natural role in movement. If the medial border of scapula flares and becomes 215
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Figure 4 Shrug exercises and retraction. Exercise starts with the individual with the arms at the side of the trunk and shoulders
in retraction (A). Perform the shrug movement (B) and return to the starting position.
Figure 5 Overhead shrug. Exercise starts with the individual standing, placing the arms in overhead position against the wall (A)
and performing a shrug movement (B) and returning to the starting position.
216 prominent, i.e. excessively internally rotated, the test Scapular pathomechanics related to altered 246
217 suggests weakness of the middle trapezius. activation of the trapezius 247
218 Finally, the strength of the lower trapezius may be tested
219 with the subject prone and the shoulder abducted to where
Appropriate activation of the trapezius and serratus anterior 248
220 the arm is parallel with the fibers of the lower trapezius
muscles is essential for optimal movement and stabiliza- 249
221 (about 120◦ ). The subject is asked to hold the arm off the
tion of the scapula. This muscular interaction has been 250
222 supporting surface as downward resistance is applied against
studied primarily during the active motions of flexion and 251
223 the arm6 (Fig. 3C). The inferior angle of the scapula pulls
abduction of the shoulder. Studies have identified that indi- 252
224 away from the thorax when the muscle is weak.
viduals with shoulder pain during elevation of the arm 253
225 The aforementioned testing positions have been shown
often present with abnormal or labored scapula movements 254
226 to produce the greatest electromyographic activity of each
in conjunction with (1) excessive activation of the upper 255
227 portion of the trapezius as compared to other positions.16 In
trapezius and (2) decreased and/or delayed activation of 256
228 addition to muscle strength, neuromuscular control should
the lower and middle trapezius and the serratus anterior.9,20 257
229 also be assessed during movement of the arm. Inade-
Specifically, excessive activation of the upper trapezius is 258
230 quate neuromuscular control may be evident by abnormal
likely associated with increased elevation of the clavicle 259
231 scapula movements, often referred to as ‘‘scapular dyski-
coupled with undesired anterior tilt of the scapula.8,21 Fur- 260
232 nesis’’. Scapular dyskinesis is commonly observed by clinical
thermore, studies suggest that decreased activation of the 261
233 observation of scapular motion during bilateral, active, non-
lower trapezius is likely accompanied with reduced scapu- 262
234 weighted and weighted elevation of the arm in the sagittal
lar upward rotation.8,20 Delayed activation of the middle 263
235 and frontal planes.17,18 Although many forms of scapular
trapezius during elevation of the arm has also been mea- 264
236 dyskinesis are possible, the following are typical patterns:
sured in individuals with shoulder pain22 and this may be 265
237 (1) the medial border and/or inferior angle of the scapula
related to undesired increased internal rotation of the 266
238 become prominent, (2) the shoulder excessively shrugs at
scapula and lack of medial stabilization of the scapula on 267
239 the beginning of arm elevation, or (3) rapid downward
the thorax. 268
240 rotation occurs during elevation of the arm.19 Presence
All the aforementioned abnormal scapular movements 269
241 of scapular dyskinesis may indicate lack of neuromuscu-
are typically associated with some underlying shoulder 270
242 lar control (muscle activation or timing) or strength of
pathology. However, it is unclear if ‘‘scapular dyskinesis’’ 271
243 the scapulothoracic muscles. A simple method to measure
is the cause or the result of shoulder pathology. Different 272
244 scapular upward rotation in a clinical setting with the aid of
mechanisms may contribute to abnormal scapular move- 273
245 a goniometer has been previously described.1,5
ments, including pain, soft tissue tightness,23,24 imbalance 274
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275 in muscle strength or activation,20 muscle fatigue25 and Table 1 Exercises that specifically target the trapezius
276 abnormal thoracic posture.26 Although speculation these muscle.
277 alterations in scapular motion during elevation of the arm
278 may alter the effective line of force of the rotator cuff Exercise Targeted muscle
279 muscles, thereby reducing the active arthrokinematics of Shrug exercises and Upper trapezius
280 the glenoid humeral joint. Furthermore, abnormal scapular retraction (Fig. 4)
281 kinematics may reduce subacromial space, thereby reducing Overhead shrug (Fig. 5) Upper trapezius
282 clearance for the rotator cuff tendons and other subacromial Prone horizontal Middle trapezius
283 structures during elevation of the arm.27 abduction (Fig. 6)
Retraction overhead Middle trapezius
284 Exercises that selectively target the activation (Fig. 7)
Prone scapular setting Lower trapezius
285 of the trapezius (Fig. 8)
Elevation with external Lower and middle trapezius
286 After a careful clinical examination, the clinician may rotation (Fig. 9)
287 decide to focus on increasing muscular strength and Prone extension (Fig. 10) Lower and middle trapezius
288 endurance of specific shoulder muscles or muscle groups. Side-lying external Lower and middle trapezius
289 In addition, it may be equally important to focus training rotation (Fig. 11)
290 on improving neuromuscular control over shoulder move- Side-lying forward Lower and middle trapezius
291 ments. Many individuals with shoulder pain do not present flexion (Fig. 12)
292 with ‘‘weakness’’ (i.e., reduced peak torque upon maxi- Prone I, T, Y (Fig. 13) Lower and middle trapezius
293 mal effort) of the trapezius and serratus anterior. Instead
294 they present with a lack of endurance, control, or timing
295 of specific muscle activation. Because the primary thera-
296 peutic goal may not be to induce muscle hypertrophy, it
297 may be useful to incorporate repetitive low-to-moderate
298 level resistive exercises to optimize the most appropriate
299 muscle activation.28 Careful cueing and feedback from the
300 therapist may be helpful. The key to improvement may lie
301 in thoughtful and careful practice of movements, with a
302 focus on building endurance and enhancing quality of the
303 movement. If muscle weakness is observed, then high-load
304 exercises may be necessary to restore strength of specific
305 muscles.
306 Based on the pathomechanics described earlier in this
307 paper, exercises may need to focus on shoulder movements Figure 6 Prone horizontal abduction. Exercise starts with the
308 that are naturally associated with minimal activation of the individual in prone and arm abducted to 90◦ with external rota-
309 upper trapezius, while still demanding substantial activation. Perform horizontal abduction.
310 tion of the lower and middle trapezius and serratus anterior.
311 Exercises that appropriately target activation of the serratus sample of these evidence-based exercises intended to serve 317
312 anterior are described in Neumann and Camargo.1 Additional as a foundation to encourage the clinician to develop even 318
313 data are available in the research literature that can help more complex trapezius-based exercises, based on the need 319
314 the clinician design exercises that either selectively target and response from the patients. 320
315 or inhibit the activation of various parts of the trapezius As a general guide to selecting certain exercises associ- 321
316 muscle during shoulder movements.29---33 Table 1 shows a ated with trapezius activation, the clinician should consider 322
Figure 7 Retraction overhead. Exercise starts with the individual standing, placing the arms in overhead position against the wall
(A) and lifting both arms (black arrows) while performing retraction (blue arrows) of the shoulders (B), then return to the starting
position.
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Figure 8 Prone scapular setting. Exercise starts with the individual lying in prone with the arm in overhead position resting on
the treatment table (A). Position the scapula in relative retraction and depression (black arrow). While maintaining this scapular
position, lift the arm slightly off the treatment table (B). Avoid shrugging the shoulder and activity of the upper trapezius.
Figure 9 Elevation with external rotation. Exercise starts with the individual standing, elbows flexed to 90◦ and an elastic band
held in hands. The elastic band is brought to tension with 30◦ of arms external rotation (A). Elevate both arms to 90◦ in the scapular
plane while holding/maintaining the tension in the band (B).
Figure 10 Prone extension. Exercise starts with the individual in prone with the arm at 90◦ of forward flexion (A). Perform
extension to neutral position with the shoulder in neutral rotation (B).
Figure 11 Side-lying external rotation. Exercise starts with the individual in the side-lying position with the shoulder in neutral
position and elbow flexed to 90◦ (A). Perform external rotation of the shoulder with a towel between the elbow and trunk (B). Avoid
compensatory movements.
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Figure 12 Side-lying forward flexion. Exercise starts with the individual in the side-lying position and the arm parallel with the
body (A). Perform forward flexion (B).
Figure 13 Prone: Making I, T, Y letters. Exercise starts with the individual lying in prone with shoulder hanging off the edge of the
treatment table (A). Position the scapula in retraction and depression. The therapist can provide feedback with hands. Maintain this
position while extending the arm posteriorly in line with the trunk (letter ‘‘I’’, B), horizontally abducting the arm (letter ‘‘T’’, C)
or elevating the arm to about 120◦ (letter ‘‘Y’’, D). Avoid activity of the upper trapezius. The black arrows indicate the importance
of maintaining relative scapular retraction and depression during the exercise.
323 the following guiding principles. Exercises that increase incorporation of middle trapezius enhanced exercises into 336
324 the strength or relative activation of the upper trapezius their rehabilitation protocol. Patients presenting either 337
325 may be counterproductive in many patients with shoul- with excessive scapular internal rotation/anterior tilt, or 338
326 der pain, especially those with symptoms of impingement. reduced scapular upward rotation, may benefit from lower 339
327 The upper trapezius naturally causes an increased ante- trapezius enhanced exercises into their rehabilitation pro- 340
328 rior tilt of the scapula, which may compromise the volume gram (Figs. 4---13). Q3 341
329 within the subacromial space. The exception may be those
330 patients that present with obvious weakness of the upper
331 trapezius and subsequently show a depressed or protracted Closing comments 342
332 posture of their shoulder girdle. Shoulder-shrug type exer-

333 cises may be appropriate in these cases. Patients presenting There is still much to be learned about the coordinated 343
334 either with excess scapular internal rotation with promi- activity of the scapulothoracic muscles. Exercises targeting 344
335 nence of the medial scapular border may benefit from the trapezius and serratus anterior muscles are commonly 345
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346 incorporated into rehabilitation programs with the aim of 17. McClure P, Tate AR, Kareha S, Irwin D, Zlupko E. A clinical 405
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BJPT 205 1---9 ARTICLE IN PRESS

4 Kinesiologic considerations for targeting activation of

10 Received 27 December 2018; accepted 17 January 2019

35 Q2 Scapular position, stability, and control play an important

The trapezius and serratus anterior act synergistically to 99

ically associated with ﬂexion or abduction of the shoulder. 101

A. Anterior view D. Posterior view

C. Superior view scupula

129 that favors an increase in the subacromial space, thereby

132 Acting in concert with the serratus anterior, forces pro-

as these muscles must offset the strong lateral translation 184

(protraction) and internal rotation force produced by simul- 185

147 ducive for effective torque production and support of the

151 control the upward rotation of the scapula is relatively min-

332 posture of their shoulder girdle. Shoulder-shrug type exer-

375 considerations in rehabilitation. Man Ther. 2011;16(1):33---39. Roentgenol. 1999;172(4):1081---1086. 440

389 2012;21(4):354---370. muscles. Man Ther. 2016;21:250---255. 454

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