Waxing Poetic About the Lower Trapezius

Christmas is coming early in 2021! Did Amelie successfully lobby an earlier Christmas to maximize her 2021 toy time? No – not yet, despite her best efforts.

Christmas is coming early for me because on November 5-6, I get to teach “Movement Systems of the Upper Extremity” with my Bosom Buddy and Co-Dependent Partner in Crime – Michael Glenn Kecman! Don’t be fooled by the vanilla course name, this weekend will be a blast! If you need any more convincing, take a gander at this little teaser (cue dramatic music and fade lights):

This is the course to end all courses! It is a compilation of 14 years of blood, sweat, and tears (mostly Kecman’s - he is a sensitive soul), by this dynamic duo. That is no typo, folks. These two have been attached at the hip for 14 years and have birthed two “love child,” courses. While no parent will admit they have a favorite child, both Kecman and Alcorn agree that this is their favorite course! Shhh, don’t tell Evaluation and Manual Therapy of the Shoulder. It is prone to jealousy.

Shameless promotions aside, teaching in The Jackson Clinics Education Curriculum truly is an honor. I get to share my love of the shoulder with the best and brightest of our company, while collaborating with my good friend. If the above teaser did not stoke your shoulder enthusiasm, how about promise of a friendly competition between Kecman and myself of “Whose kid is the cutest?” peppered throughout our lecture PowerPoint?

If neither of these sales pitches landed, I vow to win you over, waxing poetic about the Lower Trapezius.

As a shoulder nerd, an undying love of the Lower Trapezius is essential. We drone on, and on, about the Lower Trapezius, and its crucial role in the Trapezius Force Couple. The Trapezius Force Couple serves to provide a stable scapular base for the arm to move upon, in addition to facilitating the requisite upward rotation of the scapula to successfully press the arm overhead¹. 

Can we try that again, without the jargon?

We need a rock-solid lower trapezius in order to have a strong base for our arm, especially during any movement above shoulder height.

We also know that people with shoulder pain tend to demonstrate a pattern of delayed and diminished firing of the Lower Trapezius, in comparison to other muscles of the shoulder girdle¹.

With these notions front of mind, I call upon a series of exercises to improve the performance of the Trapezius Force Couple with regards to motor learning, strength, endurance, and total arm function.

Introducing the Lower Trapezius

As described in Coaching and Life Lessons from Amelie, motor learning is a relatively permanent change in the ability to execute a motor skill as a result of practice or experience². In the context of pressing overhead (a skill lost in many people with shoulder pain), I like to set people up for success, by starting with a movement is easy to perform and effective in activating the Lower Trapezius.

Bilateral External Rotation:

The bilateral external rotation movement serves this purpose because it has been shown to provide a great activation ratio of Lower Trapezius to Upper Trapezius³. Remember – people with shoulder pain tend to demonstrate reduced performance of the Lower Trapezius in relation to the Upper Trapezius with reaching overhead.

Guidance on prescription – Use this movement in a high repetition format – think 20-30 repetitions per set, performed 2-3 x daily. We are prescribing this movement as an introduction to trapezius activation. Think about how many repetitions you had to accumulate to build confidence when you were first introduced to riding a bicycle. I also like to have my patients perform these movements standing against a wall, which provides the additional tactile cue of the shoulder blades squeezing against the wall. Take a look at this picture, and the distribution of the Lower Trapezius along the inner border of the scapula⁴:

Building Capacity in the Lower Trapezius

Capacity (mobility, strength, endurance) is a precursor to motor learning – establish capacity first⁵. We rarely see mobility deficits in the Lower Trapezius, so we will focus on tactics to improve strength and endurance.

Partial Range "Y" :

The “Y” is lauded as a go-to exercise to maximize Lower Trapezius activation³ and, as a result, it is many clinician’s first choice to strengthen the Lower Trapezius. The trouble is, I often find that people with shoulder pain have trouble performing the “Y,” because it brings on said shoulder pain. In an effort to please the clinician and appease the painful shoulder, why not shorten the range of motion? Studies have shown that you can achieve a 30 degree physiologic overflow with short arc exercises⁶. This means you can achieve the benefits of strengthening the end range of the “Y,” without pain provocation. Win-Win!

Guidance on Prescription – In keeping with the American College of Sports Medicine’s Foundations of Strength Training model⁷, start with 2-3 sets of 10 repetitions. Progress this movement as quickly as tolerated, by adjusting parameters such as increasing range of motion, increasing weight, or decreasing rest time between sets.

Posterior Shoulder Endurance:

 

The “T” has been adapted to fit the endurance requirement of motor learning through the Posterior Shoulder Endurance Test (PSET). The PSET was designed to be both an endurance exercise and test for the Trapezius Force Couple⁸. It is described as follows⁸:

·         Isotonic test performed in a prone position 

·         Lift the arm to 90°of horizontal abduction at a shoulder abduction angle of 90°

·         Use cadence of 30 beats per minute

·         Original study - no external weight

·         Subsequent studies - 2% body weight used

 

Guidance on Prescription – If performing as a test, follow the instructions above, and recheck every 4-6 weeks. If performing as an endurance exercise, select the time domain that closely matches the activity of interest of the patient. Once the time domain has been established, try and progress the weight utilized, or adjust the cadence utilized, to progressively challenge.

Lower Trapezius and Total Arm Function

Push Press:

The “Push Press” is the ultimate expression of motor learning for the shoulder. Its salience is universal. We all need to reach our arms overhead at some point in our day, and the "Push Press" allows us to couple the specificity of this overhead movement with intensity (through manipulation of training variables).

Guidance on Prescription – We have already prescribed high repetition movements to fast track learning (Bilateral External Rotation) and improve endurance (PSET), and progressive loading to improve strength (Y). In the name of providing a comprehensive program, let’s utilize the principles of Speed Training, with the Push Press. Start with 3 sets of 5 repetitions with a focus on moving as fast as possible.

The Take Home:

1. The Lower Trapezius plays a crucial role in the optimal function of the shoulder and arm

2. Movement Systems of the Upper Extremity is a course not to be missed

3. Come to our course (November 5-6, 2021) to learn about all things exercise for the Lower Trapezius and total arm. Stay for the witty banter!

References:

1. Ellenbecker TS, Manske RC, Kelley MJ. The Shoulder: Physical Therapy Patient Management Utilizing Current Evidence.  Orthopaedic Section, APTA; 2016

2. Haibach-Beach P, Reid G, Collier D. Motor Learning and Development – 2^nd Edition.

3. Kevin Wilk - Current Concepts in the Treatment of Rotator Cuff Injuries – DVD (2015) 

4. Image Credit - https://www.sportsinjurybulletin.com/lower-trapezius-the-key-to-scapula-control/

5. Understanding Human Movement as a Dynamical System – Erik Meira (2018) – as part of the course: Complex Understandings for Simple Solutions

6. Clark, RA, et al. The influence of variable ROM training on neuromuscular performance and control of external loads. JCSR. 25:704-711, 2011.

7. ACSM. Progression models in resistance training for healthy adults. MSSE. 41(3):687-708, 2009.

8. Moore, Uhl, Kibler. Improvements in Shoulder Endurance Following a Baseball-Specific Strengthening Program in High School Baseball Players (2013) Sports Health A Multidisciplinary Approach 5(3):233-238.

Sprinting Down Mountains, and Other Speed-Based Fun

As most parents will attest, we are constantly amazed by the things our children attempt/accomplish, especially at an early age. My latest experience of amazement came on our trip to Maine, as I watched (and attempted to chase) my daughter running down Blue Hill Mountain, with reckless abandon.

This activity only allowed for a brief video clip, as I feared for my life/livelihood while chasing her on the rest of the descent! If this is Amelie descending a mountain, you can imagine the speed at which she pursues her flat terrain activities. Hooray speed work!

As I reflected on my potential for loss of life or limb, it got me thinking: When do we stop sprinting down hills? And for that matter, when do we slow down in all aspects of our daily movement practice?

Many of us would probably say that we notice this change as we get older.

My next question: Do we slow down because we age or, do we age because we slow down? Who says we have to stop running down the mountain just because we are not 4 years old?

Why Speed Work?

In my previous blog post, Running Away from Running, we dove into the benefits of speed training (or HIIT), as it relates to endurance training. Here are the Speed Endurance highlights^1,2:

1. HIIT causes a dramatic shift in the rate of energy depletion in the body, when compared to steady state cardio.

2. Both intensity and duration of training impact the body’s adaptation response.

3. Intensity of the stimulus is more important than the duration of the stimulus.

4. HIIT recruits more muscle fibers into the exercise – causes the muscle to use up available fuel sources faster. HIIT requires use of both fast and slow twitch muscle fibers, whereas endurance training primarily recruits only slow twitch muscle fibers.

5. HIIT increases mitochondrial density in muscles (improves the energy production/utilization capacity of the muscles)

6. HIIT is important for cardiovascular health – it improves the heart’s ability to pump blood (expressed as our VO₂ max) and improves the structure of the heart.

7. HIIT is safe for people with pre-existing conditions, such as cardiovascular disease and diabetes.

 

In an attempt to build on these principles of endurance training, why not incorporate more speed work into our entire plan of care?

 The Movements:

Speed Work Warm Up:

Why don’t we program more speed work as a warm up? The goal of the warm up is to efficiently prepare the body for activity. Per the American Heart Association, a warm up achieves this goal by dilating your blood vessels, ensuring that your muscles are well supplied with oxygen³. It also raises your muscles' temperature for optimal flexibility and efficiency³. The Amelies of the world spend their days bouncing off of walls in a perpetual state of "warm up," so their preparation time will be brief. The rest of us desk jockeys may want to take 5-10 minutes to knock the rust off of the joints with some speed work warm up movements.

Here are some examples of speed-based warm ups:

 

Jumping Jacks:

 

How about 30 seconds of Amelie Jacks to start the session and put a smile on your face? This movement provides an introduction to jumping that paves the way for the higher impact movements to come.

 

Hopping:

Next, try a couple of passes with the Amelie hop. Next stop, The Washington Ballet!

Medicine Ball Tosses:

 

The movements in this medicine ball series should warm up the upper body, trunk, and lower body. Start with 2 sets of 6 repetitions for each movement.

Speed Strength:

Utilizing speed as a component of strength training can be beneficial, as it improves your ability to produce power with your movements. Power is defined as the rate at which work is done. As it relates to exercise, power is the ability to generate lots of force in a short period of time².  As it relates to life, power is the ability to keep up with your 4-year-old daughter!

3 Pillars of Speed-Strength Training²:

1. Plyometrics – Involves the rapid stretching followed by shortening of a muscle (or group of muscles) to improve power.  Use of this stretch-shortening cycle (time to transition between eccentric phase to concentric phase) allows for greater contraction force than you would normally be able to produce during a movement. The delay between the stretching and the shortening phases needs to be very short – no longer than about ¼ second. Just remember - The quicker the eccentric contraction, the greater force generated during the subsequent concentric contraction⁴. Examples of plyometric activities include hopping, skipping, bounding, jumping, throwing, and swinging.

The kettlebell swing (shown above) incorporates the stretch-shortening cycle to engage the posterior chain (muscles on the back side of the body). This type of movement should be performed in sets of 5-10 reps in order to maintain maximum speed.

2. Speed strength^2,5 – Involves tailoring your strength movement to a speed focus, by scaling back weight and reps (similar modifications are made with our injured patient-athletes). Modifying weight and reps allows you to focus on maintaining maximal speed of movement across the entire set. Recommended volume is 3-5 sets of 3-5 reps @ 40-60% of your 1 rep maximum². The following example is a deadlift, a hinging movement similar to the kettlebell swing.

3. Complex sets² – Involves a strength exercise, immediately followed by a plyometric or speed-strength movement (ie deadlift followed by kb swing).  The rationale behind this approach is that the strength exercise primes the nervous system for explosive movement through the recruitment of more muscle fibers. Recommended approach – go heavy for 3-5 reps – rest 10 seconds – move explosively 3-5 reps – rest long (3:00).

The Speed Movement Principles:

1. The Warm Up is not your workout. It should efficiently prepare you for your workout.

2. When training speed-strength, less is more. Keep the reps low and speed high.

3. Rest long after each speed set. You want to completely recover between each set, in order to maintain speed across each rep and each set.

 

The Take Home:

Amelie has the world at her finger tips and plans to explore every nook and cranny, as quickly as possible. After taking a minute to admire her speed-based curiosity, I intend to do the same.

 

Addendum:

Please check out the References section for a list of the incredible books that have influenced my speed practice and this blog post. If you would like to learn more about how to incorporate speed training into your movement practice come hop, skip, and jump with me: https://thejacksonclinics.com/request-appointment/

 References: 

1. Gibala M. The One-Minute Workout. 2017.

2. Greenfield B. Beyond Training: Mastering Endurance, Health, and Life. 2014.

3. https://www.heart.org/en/healthy-living/fitness/fitness-basics/warm-up-cool-down

4. Wilk KE, Reinold MM, Andrews JR. The Athlete’s Shoulder – Second Edition. 2009 - Pg 751

5. Tsatsouline P. The Quick and the Dead. 2019.

Anti-Perspirant Integrity Test

My “Not-So-Baby” girl just turned four years old, so we decided to celebrate her pre-school status with a larger-than-life doll house.

While I was admiring my handiwork to assemble this monstrosity, I found myself marveling at Amelie’s determination to reach the tippy-top floor to put her Peppa Pig dolls in the attic.

This got me wondering: Why can’t many of us fully press our hands over our heads? Is it a fear of sweaty arm pits? We are in the midst of a DC summer, so I will not throw this theory out as a potential factor. Wait a minute…If this is the case, why do I also see this issue in the frigid, winter months? Is it a fear of exposing more of our bodies to the inclement weather?

Maybe, it is something far easier to explain: use it or lose it!  We stop trying to lift our arms over our heads, so we lose the ability to do so. Go ahead and try this test, I’ll be right here waiting (fully stretching my arms overhead):

Wall Flexion Test:

 

So how do we go from this:

My Muse:

To: “I can’t reach overhead, and I am moving all of the furniture to the bottom two floors of the doll house”?

 

10,000 Foot View:

People tend to fall into one (or more) of three camps – stiffness prevents overhead position, weakness prevents overhead position, pain prevents overhead position. Good news, we can treat all three, simultaneously! And, there is a ton of research that supports the utilization of overhead training in the presence of shoulder pain.

Many of my patients come in with pre-conceived notions that they should not be doing any resistance work over shoulder height. I find this puzzling, as many of the major muscles of the shoulder girdle work most effectively at progressive levels of shoulder elevation. For instance, the Serratus Anterior and Lower Trapezius muscles demonstrate improvements in activation with progressive levels of arm elevation^2-4 .  Additionally, the Overhead Press has been established as a movement that facilitates increased upward rotation and posterior tilt of the scapula, and reduced scapular internal rotation (all of these motions facilitate better reaching overhead)¹ .

What happens if I cannot get my arm fully overhead to effectively train these muscles? Train in the motion you possess! Numerous studies have shown the value of “partial range of motion” training, including a “training overflow” of 30 degrees beyond the training range^5-6. Just keep your eye on the prize, stretching ever closer towards that top floor of the dollhouse.

 

The Movements:

Broken record alert: A strong overhead game cannot be restored overnight – it will take MANY repetitions of purposeful movements, that are salient, specific, and build in intensity. ***As a dedicated reader of my previous blog posts, you may have noticed that I cut and paste this line from “Step Up Your Ground Game,” and replaced “ground game” with “overhead game.” I promise you that this is for the sake of reinforcement of principles, not the author’s laziness.

Principle of Movement – Mobility comes first! You cannot be strong in a position if you are too stiff to get there, in the first place. The following movements utilize weight/assistance to improve overhead mobility.

 

Pull Up Hold:

Haven’t hung from the monkey bars in a minute? Start with your feet on the ground. Let your body support the position and gently sink into the stretch.

 

Aspiring towards Amelie status? Pick up those feet and hold on for dear life! The longer you hold, the more time you spend working on your mobility (and strength, to boot!).

 

Dosage? Start with small sets (1-3 second holds) and progress in duration (20-30 seconds) as your tolerance improves.

 

Supine Pull Over:

Early stages of reaching overhead? Phone a friend for assistance!

Dosage? Start with small sets (20-30 second sets) and progress in duration (5:00 continuous) as your tolerance improves.⁷

 

How to progress? Sub out the dowel for some weights and repeat the process! 

Dosage? Treat it like a high rep strengthening exercise – sets of 12-20 reps.

Lat Pull Down: Doesn’t the top position look eerily similar to the top of a shoulder press?

Short on time and want to work on overhead mobility while building your back? Firstly, thank you for working on your back – even though you can’t easily see it in the mirror, a strong back is of huge importance. Secondly, here is the movement for you:

Dosage? Treat it like a high rep strengthening exercise – sets of 12-20 reps. Or, play up the tempo component, with sets of 6-8 reps with an 8-10 second eccentric. Not sure what I mean by tempo? I have a blog for that! Check out "A Not So Tempo-rary Training Tactic."

 

Principle of Movement # 2: Build strength and resilience in the range you possess. Start pressing on day one, within your good quality range of motion.

Towel Pull Apart: Early stages of reaching overhead? Phone a friend for assistance, part deux!

Dosage? Start with small sets (20-30 second sets) and progress in duration (5:00 continuous) as your tolerance improves.⁷

Sidelying Shoulder Press:

Dosage? Treat it like a high rep strengthening exercise – sets of 12-20 reps

 

Incline Press:

Dosage? Treat it like a high rep strengthening exercise – sets of 12-20 reps. Progress in weight and reduce the reps after one month.

 

Side Note – Pain is a big, hairy beast that is a separate blog unto its own. While slow, steady progression of these movements may help reduce your pain, you may need more guidance still. Suffice it to say, physical therapists thrive in the face of pain. If you have questions or concerns about pain limiting pressing overhead that cannot be addressed with these videos, schedule a consult with me and my friends at The Jackson Clinics!

 

https://thejacksonclinics.com/request-appointment/

 

The Overhead Movement Prescription:

1. Mobility is a dish best served daily. With this in mind, use the “20/20 Rule” – Every 20 minutes, step away from your work station and check the integrity of your antiperspirant (aka put your arms over your head) for 20 seconds.

2. Brush your teeth, brush your body – We brush our teeth at least twice daily to get rid of the gunk from our mouth. Why not do the same for the rest of our body, and undo the stiffness that we feel in our joints? Spend 3-5 minutes in the morning and evening exploring overhead positions.

3. Check your work – use the Wall Flexion Test after your movements and see which movements provide the biggest bang for their buck. Assess, don’t guess 😊

4. Check out my blog post, Balance the Shoulder, for specifics on exercise prescription for strength training purposes.

The Take Home:

There is a whole world of unused kitchen cabinets (and dollhouse attics) that are dying to be filled. Earn back the right to press overhead through restoration of mobility -> strength, and fill those cabinets!

 

References:
1. Ichihashi N, Ibuki S, Otsuka N, Takashima S, Matsumura A.Kinematic characteristics of the scapula and clavicle during military press exercise and shoulder flexion. J Shoulder Elbow Surg (2014) 23, 649-657.

2. Bäcker, H. C., Galle, S. E., Maniglio, M., & Rosenwasser, M. P. (2018). Biomechanics of posterior shoulder instability - current knowledge and literature review. World Journal of Orthopedics, 9(11), 245-254.

3. Bdaiwi, A. H., Mackenzie, T. A., Herrington, L., Horsley, I., & Cools, A. M. (2015). Acromiohumeral Distance During Neuromuscular Electrical Stimulation of the Lower Trapezius and Serratus Anterior Muscles in Healthy Participants. Journal of Athletic Training, 50(7), 713–718.

4. Ekstrom, R., Donatelli, R. and Soderberg, G., 2003. Surface Electromyographic Analysis of Exercises for the Trapezius and Serratus Anterior Muscles. Journal of Orthopaedic & Sports Physical Therapy, 33(5), pp.247-258.

5. George Davies - A Master Clinicians Approach to Advanced Concepts in Examination and Treatment of the Shoulder Complex – 2016.

6. Clark, RA, et al. The influence of variable ROM training on neuromuscular performance and control of external loads. JCSR. 25:704-711, 2011.

7. The role of anterior deltoid reeducation in patients with massive irreparable degenerative rotator cuff tears Ofer Levy, MD, MCh(Orth), Hannan Mullett, FRCS(TR & Orth), Sarah Roberts, Bsc(Hons), Bed(Hons), MCSP, and Stephen Copeland, FRCS, Reading, United Kingdom - J Shoulder Elbow Surg 2008;17:863-870.

Step Up Your Ground Game

The potential for falling is a constant threat in our daily lives. From the wet spot on the bathroom floor, to the missed step at the base of the stairs, and the pesky cat that is always underfoot, it is amazing we can make it through the day unscathed. While my daily struggle with my wife’s beloved cat is a nuisance, these threats become more serious with age, as our balance, strength, and mobility to overcome these falls decreases. 

10,000 Foot View:

The threat is real, folks: In the United States, 1 in 4 adults over the age of 65 fall each year and it is a leading cause of fractures and injury-related deaths, in this age group^1-4. Additionally, falls in this age group account for approximately 60% of all injury-related emergency department visits.² When do we lose the ability to safely and efficiently get down to the ground? More importantly, can we relearn this skill?

My Muse:

As per usual, I look to Amelie for guidance on all of my burning questions. My nearly 4-year-old daughter accumulates an astounding number of reps navigating the ground each day. I marvel at the effortless manner in which she lowers herself to the ground in a seemingly endless variety of Calisthenic movements. Through hundreds of daily repetitions, Amelie has developed a virtuoso ground routine that includes seamless transitions between splits and squats, rolls and crawls. As I admire the proficiency of Amelie’s movement, I reflect on how much she has developed and on my lessons learned from the world of motor learning. ***Check out my previous blog post, Coaching and Life Lessons from Amelie, for the skinny on this topic.

A strong ground game cannot be restored overnight – it will take MANY repetitions of purposeful movement, that are salient, specific, and build in intensity. Why not use this approach in the clinic, while simultaneously addressing the impairments associated with our patients’ most common injuries?

 

The Movements:

In an attempt to channel the growth mindset of the toddler/preschooler, The Jackson Clinics-Skyline utilizes a daily movement practice that encourages you to get down to the ground, improve your body control, and reacquaint yourself with all of the dust bunnies in the corner of the room and lost Peppa Pig paraphernalia under the couch.

Ground Transition Options: ***All of these options can be performed with use of upper body support on a secure surface, for additional support. Rule # 1 - No falls. Rule # 2 - Don't break rule number 1!

Lunge Strategy:

Squat Strategy:

Four Point Transition:

Two Point Transition:

While you are down there, why not spend a couple of minutes mobilizing your whole body with the following movement series? We use some variation of this sequence with virtually every patient in the clinic. Whether you have knee pain, hip stiffness, back pain, shoulder weakness, this movement series does not discriminate! The ground rocker sequence is a veritable “Swiss Army Knife,” of movement practices. So, without further ado, here it is:

Ground Rocker Series:

Quadruped Sit Backs:

Adductor Sit Backs:

Z Sit Rotations:

Z Sit Stretch:

Lunge Rockers 1-3

The Prescription:

1. 20/20 rule – Every 20 minutes, step away from your work station and practice one of the lowering options for 20 seconds.

2. Brush your teeth, brush your body – We brush our teeth at least twice daily to get rid of the gunk from our mouth. Why not do the same for the rest of our body, and undo the stiffness that we feel in our joints? Spend 3-5 minutes in the morning and evening exploring the ground rocker sequence.

3. Progress the demands – Seek out ways to make these movements more challenging. Schedule an appointment with us if you need help!

 

The Take Home: Falling is Scary Business!

1. Actively work to mitigate the risks associated with falling by reacquainting yourself with one of the first skills you learn as a child – lowering and rising from the ground.

2. Restore lost mobility, coordination, and body control through daily exposure to a ground-based movement practice.

3. Check the work of your house cleaning crew through daily, under the couch inspections!

 

References:

1. Tromp AM, Pluijm SMF, Smit JH, et al. Fall-risk screening test: a prospective study on predictors for falls in community-dwelling elderly. J Clin Epidemiol 2001;54(8):837–844.

2. Bergen G, et al. Falls and fall injuries among adults aged ≥ 65 years—United States, 2014 MMWR Morb Mortal Wkly Rep 2016 65 37 993 8

3. Centers for Disease Control and Prevention. Welcome to WISQARS (Web-based Injury Statistics Query and Reporting System). 2018. https://www.cdc.gov/injury/wisqars.

4. Bhasin S, et al. A randomized trial of a multifactorial strategy to prevent serious fall injuries. New England Journal of Medicine. 2020;383(2):129-140. doi: 10.1056/NEJMoa2002183.