Maximal scapular muscle strength results from a stabilized platform comprised of leg strength combined with hip and trunk (commonly referred to as “core”) strength and stability. Early emphasis on core strength and stability, even while the scapula and shoulder are protected, provides this proximal base for distal mobility and maximal activation. Strengthening exercises for the trunk and hip start from and end at the position of hip extension and trunk extension. These exercises include trunk and hip flexion and extension, rotation, and diagonal motions. Emphasis also should be placed on flexibility of the hips, lumbar spine, and thoracic spine, because these areas are frequently tight. The exercises should be done first to restore the base; then, they can be integrated with the scapular exercises.

To create a stable base, the rehabilitation protocols start with the primary stabilizing musculature, such as the transverse abdominis and multifidi. These groups are responsible for segmental spinal stability and provide the foundation for adequate trunk stability because of their direct attachment to the spine and pelvis; they are responsible for the most central portion of core stability. The internal and external oblique, erector spinae, rectus abdominis, and quadratus lumborum muscles then should be incorporated for trunk stability. Together, these local and global stabilizers provide ultimate core stability. The larger global muscles, including the abdominal muscles, erector spinae, and hip abductors, are vital for power generation and stability in upper extremity function. The incorporation of core strengthening into rehabilitation regimens
has been shown to increase hip extensor muscle strength and balance. Core strengthening programs also have been shown to reduce pain and increase the strength of the core musculature in patients with low back pain. This stage of rehabilitation is undertaken to restore core function but also is the first stage of extremity rehabilitation, because the core is the critical base for development and transfer of energy.

Ellenbecker and Cools have published a very useful rehabilitation algorithm to guide the implementation of scapular rehabilitation (Figure 11.1). The goals are restoration of scapular motion and periscapular muscle strength. Altered scapular motion can result from a lack of soft-tissue flexibility in the periscapular muscles or the glenohumeral muscles and capsule. The most commonly affected periscapular muscles include the pectoralis minor, short head of the biceps, upper trapezius, and latissimus dorsi. These combined inflexibilities create a forwardly tilted posture of scapular protraction. It is this alteration that frequently must be addressed at the beginning of the scapular rehabilitation program. The glenohumeral structures most commonly involved include the posterior rotator cuff musculature and the glenohumeral capsule. They affect scapular posture by increasing the tightness of the internal glenohumeral rotation so that forward arm motion or rotation “winds up” the scapula into protraction.

Stretching and mobilization techniques may be used for both types of alterations. Flexibility exercises focusing on the anterior coracoid (pectoralis minor and short head of the biceps) and shoulder rotation include the open book (Figure 11.2) and corner stretches (Figure 11.3) for the
coracoid muscles and the sleeper (Figure 11.4) and cross-body stretches (Figure 11.5) for shoulder rotation. Manual stretching and mobilization also can improve the flexibility of the periscapular muscles. Mobilization also can be effective in altering poor posture, especially thoracic kyphosis. Addressing the thoracic spine and the posterior and inferior soft-tissue components of the shoulder have been shown to be effective in correcting posture.

Taping and bracing can help to maintain increased motion, especially in patients who have improved their symptoms with postural correction or manual scapular repositioning. Several taping techniques have been used and several brands of lightweight scapular braces are available. They can be used between treatment sessions in patients who have difficulty maintaining the optimal scapular position.

Lack of muscle performance affecting scapular position and motion may derive from not only the loss of muscle strength, but also alterations in muscle activation. Periscapular strengthening should emphasize achieving a position of scapular retraction, which is the most effective position to maximize scapular roles. Scapular retraction exercises may be done in a standing position to simulate normal activation sequences and allow proximal to distal sequencing. Scapular pinch and trunk extension/scapular retraction exercises may be started early in rehabilitation, even when the shoulder is being protected, because minimal tensile load or shear is exerted on the glenohumeral joint in these exercises. The muscles most commonly found to be weak include the serratus anterior and lower trapezius. Several specific exercises have been shown to be very effective in activating the key scapular stabilizers—the lower trapezius and serratus anterior muscles—and in minimizing upper trapezius activation. They are the low row (Figure 11.6), inferior glide (Figure 11.7), fencing (Figure 11.8), lawnmower (Figure 11.9), and robbery (Figure 11.10) exercises. These are collectively called the scapular stability series. They have been shown to activate the target muscles at 18% to 30% of maximal activation. This activation, combined with the performance of these exercises at arm angles below 90° of abduction, make these exercises particularly effective in the early stages of rehabilitation, after injury or surgery.