Rehabilitation: Part II. Advanced



Fig. 32.1
Lower trapezius




32.1.1 Functions




1.

Scapular depression and adduction

 

2.

Extension of the thoracic vertebra

 

3.

Most important role for shoulder function and posture maintenance

 




  • Origin:



    • External occipital protuberance


    • Medial 1/3 of the superior nuchal line of the occipital bone


    • Ligamentum nuchae


    • Spinous process of the 7th cervical spine


    • Spinous process of all thoracic spines


    • Corresponding supraspinal ligament insertions


  • Insertion:



    • Medial end of the scapular spine


    • Tubercle at the apex of the scapular surface


32.1.2 Rehabilitation Exercise



32.1.2.1 Latissimus Pull Down


Method of exercise:

1.

Sit in front of the instrument and hold the bar with your shoulder width (Fig. 32.2a).

 

2.

Pull down the bar to your shoulder level while you are breathing out (have a feeling that you are pulling down with your shoulder) (Fig. 32.2b).

 

3.

If you hold the bar with an undergrip or lean backward while pulling the bar, more stimuli will be done on the lower trapezius.

 


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Fig. 32.2
Latissimus pull down


32.1.2.2 Posterior Fly


Method of exercise:

1.

Lie prone on the instrument with both your arms hanging down (Fig. 32.3a).

 

2.

With your elbows extended and thumbs pointing upward, lift up your arms to your shoulder level (Fig. 32.3b).

 

3.

When dropping your arm, give resistance to the upper portion of your elbows.

 


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Fig. 32.3
Posterior fly


32.1.2.3 Modified Prone Cobra


Method of exercise:

1.

Lie prone on a mat (Fig. 32.4a).

 

2.

Extend your upper body and hold your chest to be apart from the floor about 10 cm (Fig. 32.4b).

 

3.

Both palms should face away from your body and thumbs pointing upwards.

 

4.

Pull both your scapulae to maintain a finger width between the medial borders of the scapulae.

 

5.

When returning to initial position, keep your palm facing upward and give resistance.

 


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Fig. 32.4
Modified prone cobra


32.1.2.4 Prone V-Raise


Method of exercise:

1.

Lie prone on a incline bench or a stability ball (Fig. 32.5a).

 

2.

Make your shoulders 180° and abduct 120° with your elbow slightly flexed.

 

3.

With your thumb pointing upward, lift up your arms to the ear level by pulling shoulder and concentrate your scapula together (Fig. 32.5b).

 

4.

While returning to your initial position, keep your arm position, and when the trainer is giving help, give resistance above the elbows only.

 

5.

You can use a dumbbell if you have done sufficient exercise with your bare hands.

 


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Fig. 32.5
Prone V-Raise



32.2 Middle Trapezius



32.2.1 Function




1.

Function: scapular retraction, adduction, and upward rotation

 

2.

Origin:



  • External occipital protuberance


  • Medial 1/3 of the superior nuchal line of the occipital bone


  • Ligamentum nuchae


  • Spinous process of the 7th cervical spine


  • Spinous process of all thoracic spines


  • Corresponding supraspinal ligament insertions

 

3.

Insertion:



  • Medial margin of the acromion


  • Superior lip of the posterior border of the spine of the scapula

 


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Fig. 32.6
Upper trapezius (please point the upper side or trapezius muscle)


32.2.2 Rehabilitation Exercise



32.2.2.1 Seated Cable Row




1.

Bend your knees slightly and place your back in an upright position (Fig. 32.7a). Slowly pull the handle to your lower chest without moving your upper body (Fig. 32.7b).

 

2.

Return to the starting position maintaining your upper back muscle tension.

 

3.

When exercising be careful not to bounce on your upper body and try not to load pressure on your lower back by straightening it. When returning, try not to flex your lower back.

 

4.

Maximally squeezing your upper back muscle, pull up the dumbbells with the elbows brushing your body with keeping head up.

 

5.

A bar in front to prevent hyperflexion of the spine (kyphosis) makes it more effective to those with back pain and old age.

 


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Fig. 32.7
Seated cable row


32.2.2.2 Bent-Over Dumbbell Row




1.

Stand on your shoulder width, draw back hips together, and with straight back bend over 40–50° (Fig. 32.8a).

 

2.

Maximally squeezing your upper back muscle, pull up the dumbbells with the elbows brushing your body with keeping head up (Fig. 32.8b).

 

3.

It is effective to maximally contract your upper back muscle. Try not to spread your shoulders.

 

4.

Bending too much can load pressure on your lower back. So do not bend over exceeding your comfort.

 


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Fig. 32.8
Bent-over dumbbell row


32.2.2.3 Band Rowing




1.

This exercise is the same as cable row. The difference is using a rubber band. Fix the band to your feet (Fig. 32.9a), place arms beside the body, and slowly pull the band (Fig. 32.9b); then return.

 

2.

Make sure not to injure your lower back, do not move your back too much (keep it straight). Keep in mind that this exercise is not for your lower back but for your upper back.

 


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Fig. 32.9
Band rowing


32.2.2.4 Reverse Dumbbell Fly




1.

This exercise is for the posterior deltoid, but it can also help the trapezius.

 

2.

Try to concentrate on maximally contracting the upper back muscle, not the deltoid.

 


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Fig. 32.10
Reverse dumbbell fly


32.3 Upper Trapezius




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Fig. 32.11
Upper trapezius


32.3.1 Function




1.

Elevation and extension of the shoulder

 

2.

Origin:



  • External occipital protuberance


  • Medial 1/3 of the superior nuchal line of the occipital bone


  • Ligamentum nuchae


  • Spinous process of the 7th cervical spine


  • Spinous process of all thoracic spines


  • Corresponding supraspinal ligament insertions

 

3.

Insertion:



  • Posterior border of the lateral 1/3 of the clavicle

 


32.3.2 Rehabilitation Exercise



32.3.2.1 Band Shoulder Shrug




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Fig. 32.12
Band shoulder shrug


1.

Step on a rubber band with your knees flexed slightly and your back straight (Fig. 32.12a).

 

2.

Keeping your back straight, shrug your shoulders as much as you can (Fig. 32.12b).

 

3.

Do not bounce on your lower back or legs.

 

4.

Breathe in when shrugging up, breathe out when you are returning to initial position.

 


32.3.2.2 Barbell Shrug




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Fig. 32.13
Barbell shrug


1.

This exercise is well known for upper trapezius muscle exercise. Stand on your shoulder width with your knees flexed slightly and your back straight (Fig. 32.13a).

 

2.

Hold the barbell with your shoulder width and shrug as much as you can by contracting the trapezius muscle. Pause for a bit then slowly come back to the initial position (Fig. 32.13b).

 

3.

The barbell can also be held from your back.

 

4.

Breathe in when shrugging up, breathe out when returning to the initial position.

 

5.

Holding the barbell from your back can limit your lower back bending too much (kyphosis) but could be dangerous to your posture. So try with a light weight.

 


32.3.2.3 Dumbbell Upright Row




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Fig. 32.14
Dumbbell upright row


1.

Stand straight and hold the dumbbells with an overhand grip (Fig. 32.14a).

 

2.

Lift the dumbbells just below your chin, make sure both elbows are above your hands (Fig. 32.14b).

 

3.

Stay still for a while maintaining tension on your trapezius. Breathe in and lower the dumbbells beside your body.

 

4.

It stimulates trapezius muscles more in narrower grip, as opposed to the deltoids.

 


32.3.2.4 Barbell Upright Row




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Fig. 32.15
Barbell upright row


1.

Holding the barbell with a short length between the hands develops the trapezius muscle, and broad length between the hands develops the deltoid muscle.

 


32.4 Serratus Anterior


Serratus anterior is not a big muscle, but it is very important for maintaining stabilization of the scapula. Under innervation of the long thoracic nerve, this muscle originates from the first to the ninth (or tenth) rib and inserts on the medial border of the scapula. It consists of serratus anterior superior, serratus anterior intermediate, and the serratus anterior inferior. All three parts pull the scapula toward the thorax. To restate it, these muscles act together to hold the scapula in the right place.

The lower portion externally rotates and pulls forward the lower part of the scapula. This makes lifting of your arm possible. The upper portion elevates the scapula.

The serratus anterior plays a major role in scapula protraction, and this action is important in throwing or arm swinging (boxer’s muscle).

The serratus anterior stabilizes the scapula on the rib cage against the forward loading, and if the muscle does not act right, scapula winging occurs. If the scapula is not in the right place, it causes pain during ROM exercise. It also causes impingement syndrome or tear of the rotator cuff. For athletes, it causes GIRD and many other problems. Especially for baseball or volleyball players who do the throwing motion too much, weakened muscles around the scapula including the serratus anterior cause major decline for exercise capacity.

Rehabilitation must be preceded to treat the weakened serratus anterior, and many of the cases improved from rehabilitation. Before starting the treatment flexibility of the joint should be retained. Secure flexibility to those with GIRD by sleeper stretch and those with coracoid inflexibility with open book stretch.

Origin:



  • Outer surface and superior border of the first 8 or 9 ribs


  • Aponeuroses covering the intervening intercostal muscle

Insertion:



  • Ventral surface of the medial border of the scapula


32.4.1 Push-up Plus or Wall Push-up




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Fig. 32.16
Push-up plus or wall push-up

This is the main exercise. This exercise is a usual push-up including scapula protraction. It can be done on several postures and also can be done standing with your hands leaning on the wall (Fig. 32.16a). Width between your hands and height of your hands affect different parts of the muscle. Slowly exercise and unlike the usual push-up, do not use your elbow but use your scapula (Fig. 32.16b). If you don’t have sufficient muscle power, exercise against the wall or knees and elbows on the floor. Once you retain your muscle power, exercise like the usual push-up with knees not touching the floor.


32.4.2 Pull Over




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Fig. 32.17
Pull over

This exercise is for the anterior chest muscles but also has great effect for the serratus anterior. Start with not too much weight before retaining muscle power. The key point is to protract your scapula while lifting up the dumbbell.


32.4.3 Dumbbell Scapula Protraction


Exercise can be done on either one hand or both hands. Dumbbell weight can be controlled depending on your muscle power. This exercise is adequate for an initial state without sufficient muscle power.

With your arms fully extended (Fig. 32.18a), protract your scapula (Fig. 32.18b). The opposite scapula should be stuck on the floor tightly.

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Fig. 32.18
Dumbbell scapula protraction


32.5 Latissimus Dorsi




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Fig. 32.19
Latissimus dorsi


32.5.1 Functions




1.

Adduction, extension, and internal rotation of the shoulder

 

2.

Partly acts as a scapula stabilizer

 

3.

Origin:



  • Aponeurotic origin:



    • Spinous processes of the lower 6 thoracic and all lumbar and sacral vertebrae


    • Supraspinous ligament


    • Posterior part of the crest of the ilium


  • Muscular origin:



    • Muscular fasciculi from the external lip of the crest of ilium


    • Caudal 3–4 ribs


    • Inferior pole of the scapula


  • Insertion:



    • Distal part of the intertubercular groove of the humerus

 


32.5.2 Rehabilitation Exercise



32.5.2.1 Lateral Pull Down




1.

Sit in front of the instrument and hold the bar just wider than your shoulder width (Fig. 32.20a).

 

2.

Breathe in while pulling the bar to your shoulder level with a feeling of using the shoulders (Fig. 32.20b).

 

3.

It is important to make your back straight, and it is more effective when elbows are behind your back.

 

4.

Spreading your shoulders can give more stimulation.

 


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Fig. 32.20
Lateral pull down


32.5.2.2 Bent-Over Dumbbell Row




1.

Spread your legs as wide as your shoulder width, and with knees flexed slightly, and take care of your back keeping straight (Fig. 32.21a).

 

2.

Breathe out while pulling the dumbbells to the lower abdomen or pelvis by bending your elbows (Fig. 32.21b).

 

3.

Slowly return with resistance.

 


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Fig. 32.21
Bent-over dumbbell row


32.5.2.3 Body Row




1.

Hang on a horizontal bar, pull up to the midsternum of your body (Fig. 32.22a).

 

2.

Slowly lower your body with straight back keeping parallel to the floor (Fig. 32.22b).

 


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Fig. 32.22
Body row


32.6 Pectoralis Minor Muscle Exercise




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Fig. 32.23
Pectoralis minor


32.6.1 Anatomy




1.

Origin:



  • Clavicular part:



    • Anterior surface of the sternal 1/2 of the clavicle


  • Sternocostal parts



    • 1/2 the breadth of the anterior surface of the sternum (cartilages of the 6th/7th ribs)


    • Cartilages of all the true ribs


  • Abdominal parts:



    • Aponeurosis of the external abdominal oblique muscle

 

2.

Insertion:



  • Muscle rotates before its insertion



    • Lower end of the lateral lip of the intertubercular sulcus of the humerus (3 laminae)


  • Anterior part: clavicular part


  • Middle part: upper sternocostal part


  • Posterior part: lower sternocostal part and abdominal part

 


32.6.2 Function




1.

Scapula protraction – Moving the scapula forward

 

2.

Scapula depression – Moving the scapula downward

 

3.

Scapula downward rotation – lowering and rotating the inferior angle of the scapula medially

 


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Fig. 32.24
Scapula function


32.6.3 Explanation


This muscle elongates during arm elevation, upward rotation of the scapula, external rotation, and retraction of the scapula.

Also this muscle is the cause of bench-pressers shoulder when the exercise is not done in the right position or done too much.


32.6.4 Rehabilitation Exercise



32.6.4.1 Unilateral Corner Stretch




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Fig. 32.25
Unilateral corner stretch


1.

Stand up with your back straight (Fig. 32.25a).

 

2.

Flex the elbow 90° and abduct the shoulder 90°.

 

3.

Fix your hand and forearm against the wall, push your upper body to the front for 3 s. (do it like stretching your chest) (Fig. 32.25b)

 


32.6.4.2 Sitting Manual Stretch




1.

Sit on a stool with your back straight.

 

2.

Breathe in deeply.

 

3.

The trainer should hold the inferior border of the scapula and push back the coracoid process of the scapula with the opposite hand.

 

4.

Maintain for 3 s and after stretching, breathe out.

 


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Fig. 32.26
Sitting manual stretch


32.6.4.3 Supine Manual Stretch




1.

Start with lying down.

 

2.

Use a therapeutic bed or place a towel under your thoracic spine to slightly lift your scapula.

 

3.

The trainer should flex the elbow 90° and abduct the shoulder 90°.

 

4.

Then stretching is done by pushing the coracoid process of the scapula for 3 s.

 


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Fig. 32.27
Supine manual stretch


32.7 Pectoralis Minor Muscle Exercise



32.7.1 Rehabilitation Exercise



32.7.1.1 Chest Dips and Assisted Dips




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Fig. 32.28
Chest dips and assisted dips


1.

Stand between a wide dip bar. Make balance by holding the bar handle.

 

2.

With both arms extended, flex knees and cross your ankles. Lower your arm and lean forward and downward till your upper arm is parallel to the floor (Fig. 32.28a).

 

3.

Then return to the initial position (Fig. 32.28b). To improve muscle endurance, set up a possible number of exercises you can do. Repeat three times. To increase muscle size, repeat three times making a 12–15 exercise a set.

 

4.

If chest dip cannot be done, try assisted dip. Prepare in the same position, lower your arm till your upper arm is parallel to the floor. When returning to the initial position, get help from assistance.

 


32.7.1.2 Dumbbell Pull Over




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Fig. 32.29
Dumbbell pull over


1.

Lie down with the sole of your foot and your back on the floor (Fig. 32.29a).

 

2.

Hold dumbbells with both thumbs pointing to your head. With elbows slightly flexed, extend arms above your chest (Fig. 32.29b).

 

3.

Deeply breathe in and lower the dumbbells over your head. Make sure that your hips must be fixed to the floor.

 

4.

If the upper arm lies parallel to your body, stop exercising.

 

5.

While breathing out, raise dumbbells to initial position. Exercise three sets, 12–15 times a set.

 


32.7.1.3 Pec Dec Fly




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Fig. 32.30
Pec dec fly


1.

Sit on the instrument, fix your hips and back to the rear seat.

 

2.

Hold the handle, flex elbows 90°, position upper arms parallel to the floor and keep your forearms close to the pad (Fig. 32.30a).

 

3.

While breathing out, push the pad slowly to contract the pectoralis muscle (Fig. 32.30b).

 

4.

Pause at the maximum contraction point, then spread your arms while breathing in.

 


32.8 Pectoralis Major Muscle Exercise



32.8.1 Clavicular Head (Upper Head)




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Fig. 32.31
Pectoralis major clavicular head


32.8.1.1 Anatomy




1.

Origin:



  • Clavicular part:



    • Anterior surface of the sternal 1/2 of the clavicle

 

2.

Insertion:



  • Muscle rotates before its insertion



    • Lower end of the lateral lip of the intertubercular sulcus of the humerus (3 laminae)


  • Anterior part: clavicular part

 


32.8.1.2 Functions




1.

Flexion

 

2.

Transverse adduction

 

3.

Internal rotation

 

4.

Adduction

 

5.

Abduction

 


32.8.1.3 Incline Push-up




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Fig. 32.32
Incline push-up


1.

Lie prone by supporting the upper body to objects that have some height, with both arms on your shoulder width (Fig. 32.32a).

 

2.

Make your body straight, even when exercising remember to position your hips and legs in a straight line.

 

3.

While breathing in, continue to lower your arms before your chest touches the floor (Fig. 32.32b). Then pause for 1–2 s. Breathe out and extend your arms to return.

 

4.

When lowering your arms, elbows should point away from your body and exercise slowly from fully extended position.

 

5.

Give more resistance using a band. Exercise by coiling around your back and fix it with both hands.

 

6.

Patients with shoulder pain can exercise by externally rotating both hands 45° to lower resistance.

 


32.8.1.4 Incline Bench (Dumbbell) Press




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Fig. 32.33
Incline bench (Dumbbell)press


1.

Lie down on a 15–45° inclined bench (Fig. 32.33a).

 

2.

Hold a barbell or dumbbells on your shoulder width. Raise by pushing your elbow while breathing in and return by breathing out (Fig. 32.33b).

 


32.8.2 Sternal Head




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Fig. 32.34
Pectoralis major sternal head


32.8.2.1 Anatomy




1.

Origin:



  • Sternocostal parts



    • 1/2 the breadth of the anterior surface of the sternum (cartilages of the 6th/7th ribs)


    • Cartilages of all the true ribs

 

2.

Insertion:



  • Muscle rotates before its insertion



    • Lower end of the lateral lip of the intertubercular sulcus of the humerus (3 laminae)


  • Middle part: upper sternocostal part

 

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Oct 16, 2016 | Posted by in SPORT MEDICINE | Comments Off on Rehabilitation: Part II. Advanced

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