Accepted Manuscript

Scapular muscle activity in a variety of plyometric exercises

Maenhout Annelies, Benzoor Maya, Werin Mia, Cools Ann

PII: S1050-6411(16)00006-7
DOI: http://dx.doi.org/10.1016/j.jelekin.2016.01.003
Reference: JJEK 1938

To appear in: Journal of Electromyography and Kinesiology

Received Date: 22 June 2015

Revised Date: 26 November 2015
Accepted Date: 15 January 2016

Please cite this article as: M. Annelies, B. Maya, W. Mia, C. Ann, Scapular muscle activity in a variety of plyometric
exercises, Journal of Electromyography and Kinesiology (2016), doi: http://dx.doi.org/10.1016/j.jelekin.
2016.01.003

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Scapular muscle activity in a variety of plyometric exercises.

Maenhout Annelies1, Benzoor Maya2, Werin Mia1, Cools Ann1

1
Ghent university, Department of rehabilitation medicine and physiotherapy, Campus

Heymans, De Pintelaan 185, 9000 Ghent, Belgium.

2
Ribstein Center for Sports Medicine and Research at the Wingate Institute, Netanya, Israel

42902 and Department of Physical Therapy, University of Haifa, Sderot Abba Hushi 199,

Mount Carmel Haifa, 3498838

Corresponding author:

Annelies.maenhout@ugent.be

Word Count: 3068

1
INTRODUCTION

The shoulder is a unique composite joint with very little bony stability. Moreover, the

relatively small sternoclavicular joint is the only bony connection of the shoulder girdle to

the trunk. For this reason the shoulder largely depends on the delicate coupling of muscular

actions for efficient motion.12 Muscles originating from the scapula run in two directions,

being the thorax and the humerus. When moving our hand, scapulothoracic muscles need to

stabilize the scapula to allow initiation of upper arm movement by the scapulohumeral

muscles.19 The better the scapula can be stabilized, the more efficient rotator cuff muscles

can work with high velocity and maximal power of the upper arm as a result.19;21;22

Plyometric exercises are often used to train this capacity of the shoulder as they combine

strength with speed of glenohumeral joint motion, which is quite challenging for scapular

stability.6 This type of exercises finds its use in sports specific training and the return to play

phase of rehabilitation in overhead athletes with shoulder injury.33 Plyometric shoulder

4
exercise programs have previously been shown to improve throwing speed and distance

and to enhance proprioception and kinesthesia.36 In practice, information on scapular

muscle activation during plyometric exercises is helpful to support exercise selection for

scapular muscle strengthening or balance correction. Ellenbecker et al recently published a

study on muscular activation in 2 plyometric exercises at 90° abduction.15 Both the prone

90/90 external rotation plyometric exercise and the reverse catch showed moderate to high

levels of activation of lower trapezius, serratus anterior and infraspinatus.

This study aims to elaborate on this by analyzing scapular muscle activation during a variety

of exercises with different positions of the body, different types of exercise weight and

2
different positions of the shoulder. Moreover this study aims to look at scapular muscle

activity separately in the back and forth movement of each exercise.

METHOD

Participants

Thirty-two young healthy subjects (Male/Female: 14/18) volunteered for this study. To be

eligible for this study subjects had to be aged between 18 and 35, be free from any shoulder

or neck pain at the time of the study and during 6 months preceding the study, never had

shoulder surgery nor fracture in the upper limb and not perform more than 6 hours of

overhead activity/week.

Mean age of the study group was 23.33 years (1.69 years), mean height 1.73m (0.09m),

mean weight 66.5kg (9.1kg). All subjects gave informed consent. The Ethical Committee of

Ghent University Hospital (Ghent, Belgium) approved the investigation.

Instrumentation

A wireless Noraxon TelemyoTM Direct Transmission System (DTS) (Noraxon USA, Inc.,

Scottsdale, Arizona) was used for registration of EMG activity of the three trapezius parts

and SA. Sample rate for data collection was 3000Hz. The device had a common mode

rejection ratio of 115dB. Gain was set at 1000 (signal to noise ratio <1V RMS).

The dominant shoulder electrode attachment places were shaved, scrubbed and cleansed

with alcohol. Bipolar Ag-Cl surface electrodes (Blue sensor, Medicotest, Ballerup, Denmark)

were placed over upper (UT), middle (MT) and lower trapezius (LT) and serratus anterior (SA)

by the same examiner in all subjects. SENIAM (Surface ElectroMyoGraphy for the Non-

Invasive Assessment of Muscles) recommendations were followed for electrode placement

3
and interelectrode distance.17 Electrodes for UT were placed halfway between the spinous

process of C7 and the posterior acromion. For registration of MT activity, electrodes were

placed halfway on the horizontal line between the thoracic spine and the root of the

scapular spine. Electrodes for registration of LT activity were placed obliquely upward and

laterally along a line between the intersection of the scapular spine with the vertebral

border of the scapula, and the seventh thoracic spinous process. 3;7 Electrodes for SA

registration were applied anterior to the latissimus dorsi and posterior to the pectoralis

major.10;26 Correct electrode placement was checked by shoulder shrugging for UT, shoulder

retraction for MT and LT and shoulder protraction for SA.

Kinematic data were collected with an Optitrack highspeed camera (FPS). A reflective marker

was applied on the subject with double sided tape to track direction of motion during the

exercises. The marker was placed laterally on the distal ulna, 5cm proximal to ulnar styloid

process, for exercise 1 to 4, dorsally on the distal forearm, 5cm proximal to the unlar head,

for exercise 5 and 6 and laterally on the trunk, at the level of the seventh rib, for exercise 7

to 10. The camera was installed perpendicular to this reflective marker for each exercise.

Testing Procedure

In the first part of the investigation, maximal voluntary isometric contractions (MVIC) of UT,

MT, LT and SA were quantified in a randomized order.3;7;9 MVIC of UT was measured during

resisted isometric abduction. Participants were seated with the arm abducted 90° in the

frontal plane.34 For MT, participants were lying prone with their dominant arm abducted 90°

and externally rotated and resistance was applied to additional horizontal abduction. For LT,

participants were lying prone with their dominant arm abducted 145°. Resistance was

4
applied to additional flexion. MVIC of SA was quantified seated with the arm flexed forward

130° and resistance was applied to additional elevation. Subjects were instructed to give

absolute maximal resistance to the investigator. Data were recorded from the moment the

subject started to give resistance. When the investigator felt that the subject was at his/her

maximum a marker was placed and 5 more seconds were recorded from this moment on.

The placement of this marker was corrected afterwards when this did not coincide with the

period of maximal EMG signal measured. The same investigator gave resistance in all

subjects and verbally encouraged the participants in a standardized way. Three trials were

performed with 15 seconds rest in between contractions, controlled by a metronome (60

bpm). Between MVIC measurements of different muscles, 2 minutes rest were provided.

After MVC recording, participants performed 10 exercises in a randomized order (generated

through an online randomization software program37) to avoid systematic fatigue influences.

The exercises were selected based on their frequent use in rehabilitation of overhead

athletes. All exercises had a plyometric character, meaning that a stretch shortening cycle

was used. Muscles worked with high velocity alternating between concentric and eccentric

contractions requiring acceleration and deceleration of the exercise weight or body weight.

Both open and closed chain exercises were included and different materials were used

(Bosu® (BOSU® Official Global Headquarters, Ohio, USA), Theraband® Soft weights (The hygienic

corporation, Ohio, USA) and Xco® Trainer (FLEXI SPORTS GmbH, München, Germany). The

amount of weight (from 0,5kg to 3kg) or type of Xco®Trainer (long or short) was chosen so

that participants rated the exercises between 12 and 18 on Borg scale of 20, which is

considered the effort needed to train strength.1;16 Standardized exercise instructions are

presented in Table 1. Each subject was instructed until performance was correct. Muscle

5
activity was recorded during all exercises for an equal amount of time (30 seconds). Thirty

repetitions were performed at a pace of 1 rep/s (monitored with a metronome) for all

exercises except the Xco® Trainer exercises which were double speeded in order to have

smooth plyometric muscle contractions (resulting in 60 repetitions).

Signal Processing and Data Analysis

The myoVIDEO module of the Noraxon MR 3.4 Software Program was used for signal

processing. Raw EMG signals were rectified, smoothed (RMS 50ms) and ECG reducted. The

mean EMG activity of the three seconds interval after the marker (placed at time point

where the investigator objectively felt maximum force was reached) was used for further

analysis. When this interval did not contain the highest EMG activity (based on visual

inspection), the marker was manually replaced. This method was chosen as it was seen in

previous investigations at the department that a subject needs a couple of seconds to reach

his/her maximal force. This method ensures that theinterval contains the maximal EMG

signal.

Motion of the reflective marker on the arm of the subject was analysed to track the start and

end of the back and forth movement of all repetitions.

The 5th to 20th repetition of all exercises at a pace of 1 rep/s was used (15 repetitions) and 5th

to 35th repetition of exercises at a pace of 2 reps/s were used (30 repetitions). EMG data of

the 4 muscles were averaged across this phase and expressed as a percentage of the MVC

representing muscle activity during the exercise. EMG data were averaged across the

uneven (back) phases and across the even (forth) phases separately, both expressed as a

percentage of the MVC representing respectively muscle activity during the back and forth

movement of the exercises. The muscular activity classification used in this study included

6
0% to 15% as absent to minimal, 16% to 30% as low, 31% to 60% as moderate, and greater

than 60% as high.

STATISTICAL ANALYSIS

SPSS 22.0 for Windows (SPSS Science, Chicago, III) was used for statistical analysis. All

outcome variables were normally distributed (based on Shapiro Wilk test). To compare

scapular muscle activity between the variety of exercises, a 2way Anova for repeated

measures was used with “muscle” (4 levels) and “exercise” (10 levels) as within subjects

factors. When Mauchley’s test of sphericity was significant, Greenhouse-Geisser correction

was applied. Post hoc tests with Bonferroni correction were performed for 9 comparisons:

Exercise 1 versus 2, exercise 3 versus 4, exercise 5 versus 6, exercise 1 versus 3, exercise 1

versus 5, exercise 7 versus 8, exercise 8 versus 9, exercise 8 versus 10.

Paired sample t-tests were performed to compare muscle activity within each exercise

during the back and forth movement for each muscle.

RESULTS

Mean scapular EMG activity during the 10 exercises ranged from 14.50 to 76.26% MVC for

UT, from 15.19 to 96.55% MVC for MT, from 13.18 to 94.35% MVC for LT and from 13.50 to

98.50% MVC for SA. Figure 1 displays mean scapular muscle activity for the 10 plyometric

exercises used in this investigation. Statistical analysis showed a significant interaction effect

of muscle x exercise (p<0.001, power= 1.000). Results of the post-hoc tests are displayed in

Table 2. Highest MT and LT activity were found the prone plyometric exercises (ex. 1:

87.80%MVC ±30.41 MT activity and 94.35%MVC ±44.40 LT activity , ex. 2: 96.55%MVC

±36.13 MT activity and 91.35%MVC ±35.61 LT activity). Exercises with the highest SA activity

7
were the ones using the Xco® Trainer and the Bosu® push up (ex. 6: 98.50%MVC ±4.81, ex. 5:

61.91%MVC ±26.38 and ex. 7: 62.81%MVC ±37.04).

The lowest UT activity was registered in the sidelying plyometrics (ex. 3: 15.78%MVC ±8.66

and ex. 4: 16.70%MVC ±10.80) and the plyometric Bosu® push up (ex. 7: 14.50%MVC

±10.31).

Figure 2 shows mean scapular muscle activity separately in the back and forth movement for

each exercise. The results of the comparison of scapular muscle activity between these two

phases are displayed in Table 3.

DISCUSSION

Plyometric exercises are useful in the return to play phase of overhead athlete rehabilitation

to progress from slow analytic strength training exercises to more demanding sports-specific

activities.32;38 In literature, multiple studies examined scapular muscle activity during analytic

strength training exercises.1;9;11;14;24-26;28-31;39 This information is helpful for clinicians to select

exercises to target or rather inhibit specific scapular muscles. Only one study could be found

in literature that examined scapular muscle activation during plyometric exercises.15 The aim

of this study was first to investigate scapular muscle activity in a variety of commonly used

plyometric shoulder exercises to support exercise selection in clinical practice. Second, this

study aimed to enhance understanding of how scapular muscles are recruited during the

back and forth phases of plyometric shoulder exercises.

8
From this investigation, it was shown that the proposed exercises require in general

moderate (31-60%MVC) to high (>60%MVC) trapezius and SA muscle activation and that

there is a selection of exercises that require low levels of upper trapezius activity (<20%).

Targeting MT, LT and SA in shoulder exercise programs is important as these muscles are

thought to contribute to good scapular stabilization, needed for efficient energy transfer

during high load shoulder motion.20 Exercises in this study that displayed highest MT and LT

activity are the two prone plyometric exercises with a soft weight (90/90 external rotation

and forward flexion). In the study of Ellenbecker et al, the activation level of LT during the

90/90 external rotation exercise, was lower (61%) compared to this study (87,80%). MT

activity was not measured in their study nor did they investigate any of the other exercises.

This difference in activation level of LT might result from the higher dosage in the present

study using the Borg scale (13 subjects used 1kg or less, 19 subjects used 1.5kg or more)

compared to the fixed weights of 0,5 and 1 kg in the study of Ellenbecker et al. 15

Exercises with the highest SA activity were the standing exercises with the Xco® Trainer

(90/90 internal-external rotation and forward flexion) and the Bosu® push up. The

plyometric wall push up exercises displayed only moderate (31-60%MVC) SA activity levels

and might therefore be suited earlier in the strength training programme. Interestingly,

performing a one legged wall push up increases SA activity compared to bipodal with the

largest difference seen in the wall push up on contralateral leg. This is in line with previous

investigations showing higher SA activity in closed chain exercises supporting on the

contralateral leg. It is hypothesized that SA is more active when it is recruited in the anterior

diagonal flexion chain that runs from the contralateral hip flexion musculature and internal

oblique abdominal muscle to the ipsilateral external oblique abdominal muscle and serratus

anterior.28

9
In practice, clinicians often aim to inhibit UT during exercises as this hypertonic muscle tends

to overrule other scapular muscles and this is thought to be related to dyskinesis of the

scapula.9 The lowest UT activity was registered in the sidelying plyometric exercises and the

plyometric Bosu® push up. This is in agreement with previous studies that demonstrated a

low ratio of UT versus MT and UT versus LT during side lying exercises and a low ratio of UT

versus SA during push up exercises.9;27;28

The exercises in this study differed from each other in different aspects, being position of the

body and shoulder and equipment used to resist.(Table 1) Comparing similar exercises

(90/90 external rotation and flexion) using different equipment for resistance (Theraband®

soft weights and Xco® Trainer) showed that during the exercises with soft weight, MT and LT

are significantly more active (difference ranging from 44.43 to 54.21%MVC) while during

exercises with the Xco® Trainer, SA is more active (difference ranging from 40.57 to

42.89%MVC). Higher activation of MT and LT using a soft weight is probably related to the

gravitational forces in the prone position resisting only the backward movement. The Xco®

Trainer exerts resistance both during the back as well as the forth movement of the shoulder

which might explain the need for higher SA activity. To allow isolated comparison between

the use of soft weights and the Xco® Trainer, the exercises should have been performed in

the same body position. Practical reasons for this are first that it is impossible to perform the

soft weight exercises standing and second, that there was no practical argument to perform

the exercises with the Xco® Trainer prone as this position is less functional for the overhead

athlete. One should take that into account when interpreting these data. Overall, it can be

advised that, to train posterior stabilizers of the scapula (MT, LT), prone exercises with a soft

10
weight are preferred while to train anterior stabilizers of the scapula (SA), using the standing

exercises with the Xco® Trainer are most eligible.

When similar exercises with different shoulder positions were compared, it was shown that

forward flexion movement in the exercise results in higher recruitment of UT and SA

compared to the 90/90 external rotation. This UT-SA force couple assists in the upward

rotation that is necessary in the end ranges of forward flexion. When high activity of UT is

not desirable, it is not recommended to select these forward flexion exercises.

This study has the advantage of featuring information of scapular muscle activity separately

during the back and forth phases of each exercise. From this analysis it is clear that during

the exercises with a soft weight, all three parts of the trapezius work especially during the

backward movement in both prone and side lying position. SA on the other hand works

more during the forward movement. However, this changes when a forward flexion

movement is performed. In this case, SA will assist in scapular upward rotation during the

backward movement as well, resulting in equal activity during the whole exercise.

In exercises using the Xco® Trainer the trapezius muscle parts also display higher activity in

the backward phase. SA on the other hand will work with equal activity levels in the back

and forth movement when performing a 90/90 external/internal rotation. When forward

flexion is performed, higher SA will again be required to assist in upward rotation resulting in

higher activity during the backward compared to forward movement.

In the closed chain exercises SA showed to be more active in the backward push off phase

compared to the forward landing phase with the difference between phases increasing with

increasing load (Bipodal wall push up < Wall push up on ipsilateral leg < Wall push up on

11
contralateral leg < Bosu® push up). Little to no difference in activation was seen here for

trapezius muscle parts between phases.

There are some inherent limitations to this study, however, that restrict generalization of

the results. Care should especially be taken when using the results to guide exercise

selection in patients with shoulder pain. Given that several studies in the past showed a

different scapular muscle activity in the presence of pain2;5;8;18;35, this could also be reflected

in their scapular muscle activity patterns during these plyometric exercises. However, these

exercises should not be performed in the acute phase of injury where pain is present but

rather in the return to play phase of rehabilitation.

Another limitation of the study is inherent to the use of surface EMG. Precautions were

taken by following SENIAM prescriptions and by maximal standardization and accuracy. 17 In

addition recommendations of previous investigations that used surface EMG to analyze

scapular muscle activity were strictly followed.9;13;23;27 However, despite precautions,

crosstalk could have occurred during measurements.

CONCLUSION

The variety of plyometric exercises that were subject of this investigation showed overall

moderate (31-60%MVC) to high (>60%MVC) activation of scapular muscles. Specific

exercises can be selected to target MT, LT and/or SA or rather to inhibit UT in strength

training programs. Different positions of the body and shoulder and different resistive

equipment largely influence scapular muscle activation. The results of comparing these

exercises might assist exercise selection in clinical practice.

12
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16
TABLES

17
Nr. Exercise
1 Prone external rotation
with soft weight
2 Prone forward flexion with
soft weight
3 Sidelying external rotation
with soft weight
4 Sidelying horizontal
abduction with soft weight
5 Standing external rotation
with Xco®
6 Standing flexion with Xco®
7 Plyometric push up on
Bosu®
Performance
Subject is prone on physiotable, diagonally positioned with shoulder
(glenohumeral joint) just over the table
Head is rotated towards exercising arm
Contralateral arm is with the hand under the head
The exercise is performed by a drop of the ball after a plyometric horizontal
abduction with external rotation, followed by a delayed catch of the ball,
meaning that the ball is caught below table level
Attention is paid to compensations: no elevation of the scapula is allowed,
head should stay supported on the table, no deviation from 90° abduction
and the subject should keep the external rotation component, no throwing
of ball with a dominant wrist extension is allowed
Subject is prone in same position as exercise 1
Shoulder is in forward flexed position (180°)
Exercise is performed by quick lift of the ball above level of table, followed
by a drop of the ball and a catch below table level
Attention is paid to compensations: no elevation of the scapula is allowed,
head should stay supported on the table, no deviation from 180° forward
flexion, no throwing of ball with a dominant wrist extension is allowed
Subject is sidelying, hips and knees 45° flexed to be in a stable position
Head supported by cushion, contralateral hand under the cushion
Shoulder is adducted but not supported by the trunk
Elbow flexed 90°
Exercise is performed with external rotation to throw the ball in the air,
followed by a delayed catch of the ball just above the ground
Attention is paid to compensations: head should stay supported by the
cushion, arm should stay as much as possible in adduction, no forward
flexion allowed, no dominant wrist extension during the throwing of the
ball is allowed
Subject is sidelying, hips and knees 45° flexed to be in a stable position
Shoulder is at 90° forward flexion, scapula in a retracted position
Exercise is performed by a quick horizontal abduction to throw the ball in
the air, followed by a delayed catch of the ball just above the ground
Attention is paid to compensations: no retraction/protraction is allowed
while performing the exercise, no wrist extension to throw the ball
Subject is standing, contralateral leg forward, ipsilateral leg backward, no
rotation in trunk and pelvis, shoulder at 90° abduction and 90° external
rotation
Xco is in anteroposterior direction
Exercise is performed by alternating internal and external rotation, the
sand should be heard when it reaches the bottom of the Xco
Attention is paid to compensations: no wrist movements, no lowering of
the arm, no horizontal abduction/adduction during exercise, trunk is kept
stable during exercise and head stays in neutral position
Subject is standing, contralateral leg forward, ipsilateral leg backward, no
rotation in trunk and pelvis, shoulder at 180° flexion
Xco is in anteroposterior direction
Exercise is performed by alternating flexion/extension, the sand should be
heard when it reaches the bottom of the Xco
Attention is paid to compensations: no wrist movements, no elevation of
scapula, no trunk movements, head stays in neutral position
Subject on knees, no flexion in hips allowed
Hands beneath shoulders supported on the convex side of the Bosu® ball, a
little bit behind the centre top
“Jump” on the bosu® with flexion/extension of elbows and horizontal ab-
/adduction of the shoulder
Elbows should go laterally and a bit distally in the subjects view
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 Trunk should be kept in 1 line during the exercise
Feet and lower leg are lifted from the ground during exercise
Pay attention to good scapular position with posterior tilt and the head
should be kept in line with the trunk, no protraction of the head is allowed
8 Bipodal plyometric wall Subject is standing face to wall, feet are on hip width at an arm length and
push up 2 foot lengths distance from the wall.
Hands are supported on the wall with 90° shoulder flexion.
The exercise starts with pushing off from the wall until hands are free and
then catching again. Attention is paid to good core stability (no movement
in low back and hips)
9 Plyometric wall push up on Same performance as exercise 8 but subject lifts the contralateral leg from
ipsilateral leg the ground and stands on the ipsilateral leg.
10 Plyometric wall push up on Same performance as exercise 8 but subject lifts the ipsilateral leg from the
contralateral leg ground and stands on the contralateral leg.

Table 1. Exercise instructions

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Comparison Figures Item of comparison UT (Mean SD MT (Mean SD LT (Mean SD SA (Mean SD Clinical conclusion
(A vs. B) difference A-B) difference A-B) difference A-B) difference A-B)
1 vs. 2 shoulder external rotation -33.06%MVC 21.00 No sign diff / No sign diff / -29.85%MVC 32.43 Higher UT and SA activity in
versus forward flexion (p<0.001) (p<0.001) forward flexion

3 vs. 4 shoulder external rotation No sign diff / -13.38%MVC 19.49 -18.95%MVC 14.06 -6.50%MVC 12.64 Higher MT and LT activity in
versus horizontal flexion (p=0.001) (p<0.001) (p=0.007) horizontal flexion

5 vs. 6 shoulder external rotation -15.26%MVC 22.73 No sign diff / No sign diff / -36.59%MVC 31.26 Higher UT and SA activity in
versus forward flexion (p=0.001) (p<0.001) forward flexion

1 vs. 3 prone versus side lying 26.95%MVC 13.88 53.38%MVC 37.24 68.85%MVC 32.64 9.03%MVC 17.31 Higher UT, MT, LT and SA
90°abduction versus (p<0.001) (p<0.001) (p<0.001) (p=0.007) activity prone
adduction
1 vs. 5 prone versus standing No sign diff / 44.43%MVC 30.69 51.98% MVC 29.99 -40.57%MVC 22.13 Higher MT and LT activity prone
Soft weight versus Xco (p<0.001) (p<0.001) (p<0.001) with soft weight
Higher SA activity standing with
Xco

2 vs. 6 prone versus standing 17.91%MVC 26.60 54.21%MVC 28.31 49.17%MVC 27.09 -42.89%MVC 34.10 Higher UT, MT and LT activity
Soft weight versus Xco (p=0.001) (p<0.001) (p<0.001) (p<0.001) prone with soft weight
Higher SA activity standing with
Xco

7 vs. 8 Bosu® versus wall -15.23%MVC 15.28 No sign diff / No sign diff / 23.30%MVC 27.29 Lower UT activity on Bosu®
(p<0.001) (p<0.001) Higher SA activity on Bosu®

8 vs. 9 bipodal versus unipodal on No sign diff / No sign diff / -2.38%MVC 5.41 -11.46%MVC 22.53 Higher LT and SA activity on
ipsilateral leg (p=0.018) (p=0.007) ipsilateral leg

8 vs. 10 bipodal versus unipodal on No sign diff / No sign diff / No sign diff / -15.79%MVC 40.19 Higher SA activity on
contralateral leg (p=0.034) contralateral leg

Table 2. Post hoc pairwise comparisons of total mean normalized EMG activity of upper trapezius (UT), middle trapezius (MT), lower trapezius (LT) and serratus anterior
(SA) between exercises. (1.Prone external rotation, 2.Prone forward flexion, 3.Side lying external rotation, 4.Side lying horizontal abduction, 5.Standing rotation, 6.Standing
forward flexion, 7.Push up on Bosu®, 8.Wall push up bipodal, 9.Wall push up on ipsilateral leg, 10.Wall push up on contralateral leg)

20
 LT Mean
UT Mean MT Mean SA Mean
difference
Exercise Phase definition difference SD difference SD SD difference SD Conclusion
(Back-
(Back-Forth) (Back-Forth) (Back-Forth)
Forth)
During throwing of the ball there is
Back= throwing ball (external rotation) 9.34%MVC 11.17%MVC 9.66%MVC -10.25%MVC higher UT, MT and LT activity
1 12.36 21.33 22.20 13.09
Forth= catching ball (internal rotation) (p<0.001) (p=0.006) (p=0.02) (p<0.001) During catching of the ball there is
higher SA activity
During throwing of the ball there is
Back= throwing ball (flexion) 12.14%MVC 20.41%MVC 19.28%MVC
2 20.11 24.49 26.04 No sign diff / higher UT, MT and LT activity
Forth= catching ball (extension) (p=0.002) (p<0.001) (p<0.001)
SA is equally active in both phases
During throwing of the ball there is
Back= throwing ball (external rotation) 6.65%MVC 18.14%MVC 9.27%MVC -3.37%MVC higher UT, MT and LT activity During
3 9.40 20.52 13.28 6.40
Forth= catching ball (internal rotation) (p<0.001) (p<0.001) (p<0.001) (p=0.006) catching of the ball there is higher SA
activity
During throwing of the ball there is
Back= throwing ball (horizontal abd) 8.79%MVC 32.80%MVC 26.12%MVC -11.09%MVC higher UT, MT and LT activity During
4 10.13 37.96 25.67 12.46
Forth= catching ball (horizontal add) (p<0.001) (p<0.001) (p<0.001) (p<0.001) catching of the ball there is higher SA
activity
During external rotation motion there is
Back= external rotation motion 18.11%MVC 21.29%MVC 13.49%MVC
5 23.81 29.60 19.91 No sign diff / higher UT, MT and LT activity SA is
Forth= internal rotation motion (p<0.001) (p<0.001) (p=0.001)
equally active in both phases

Back= backward flexion motion 24.23%MVC 14.39%MVC 15.51%MVC 18.47%MVC During backward flexion motion all
6 25.29 20.71 21.08 38.57
Forth= forward extension motion (p<0.001) (p=0.001) (p<0.001) (p=0.012) scapular muscles are more active

Back= push off phase 33.54%MVC

7 No sign diff / No sign diff / No sign diff / 26.78 During push off phase SA is more active
Forth= landing phase (p<0.001)
During push off phase SA and UT are
Back= push off phase 8.56%MVC -3.96%MVC 24.09%MVC more active
8 10.34 No sign diff / 7.01 10.58
Forth= landing phase (p<0.001) (p=0.003) (p<0.001) During landing phase LT is slightly more
active
Back= push off phase 6.99%MVC 28.35%MVC During push off phase SA and UT are
9 9.80 No sign diff / No sign diff / 23.06
Forth= landing phase (p<0.001) (p<0.001) more active
During push off phase SA and UT are
Back= push off phase 6.14%MVC -5.80%MVC 30.99%MVC more active
10 9.31 No sign diff / 6.43 24.53
Forth= landing phase (p=0.001) (p<0.001) (p<0.001) During landing phase LT is slightly more
active
Table 3. Paired sample t-tests of back and forth movement mean normalized EMG activity of upper trapezius (UT), middle trapezius (MT), lower trapezius (LT) and
serratus anterior (SA) within exercises. (1.Prone external rotation, 2.Prone forward flexion, 3.Side lying external rotation, 4.Side lying horizontal abduction, 5.Standing
rotation, 6.Standing forward flexion, 7.Push up on Bosu®, 8.Wall push up bipodal, 9.Wall push up on ipsilateral leg, 10.Wall push up on contralateral leg)

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ILLUSTRATIONS

Fig. 1. Mean normalized EMG activity of upper trapezius (UT), middle trapezius (MT), lower trapezius (LT),
and serratus anterior (SA) for all 10 exercises (1.Prone external rotation, 2. Prone forward flexion, 3.Side lying
external rotation, 4.Side lying horizontal abduction, 5.Standing rotation, 6.Standing forward flexion, 7.Push up
on Bosu®, 8.Wall push up bipodal, 9.Wall push up on ipsilateral leg, 10.Wall push up on contralateral leg)

Fig. 2. Mean normalized EMG activity of upper trapezius (UT), middle trapezius (MT), lower trapezius (LT),
and serratus anterior (SA) for the back (grey) and forth (black) movement phase of all 10 exercises (1.Prone
external rotation, 2.Prone forward flexion, 3.Side lying external rotation, 4.Side lying horizontal abduction,
5.Standing rotation, 6.Standing forward flexion, 7.Push up on Bosu®, 8.Wall push up bipodal, 9.Wall push up on
ipsilateral leg, 10.Wall push up on contralateral leg)

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 UT MT LT SA

120
EMG Muslce activity (% MVC)

MT SA
100 LT LT
MT
UT
80
SA SA
UT SA
60 SA SA
MT LT
UT UT MT LT MT LT SA
40 MT
UT UT UT
SA LT
SA
UT SA UT UT MT LT MT LT MT LT MT LT
20

0
1 2 3 4 5 6 7 8 9 10
Exercise

Figure 1

23
 120 SA
MT
EMG Muscle activity (%MVC)

LT LT UT Back movement Forth movement

100 MT
UT
UT MT SA
SA
80 LT SA
MT LT SA MT
SA LT
60 UT SA
MT
40 SA LT UT UT UT
SA MT LT LT
MT LT
UT SA UT UT MT LT MT
20
0
1 2 3 4 5 6 7 8 9 10
Exercise

Figure 2

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Annelies Maenhout (PhD, PT) is a sports physiotherapist at the Sports Medical Centre of the
University Hospital in Ghent, Belgrium and teacher at the Artevelde University College in Ghent,
Belgium. She obtained her PhD in 2012 from the University of Ghent (Belgium) on the topic of the
role of intrinsic and extrinsic factors in rotator cuff tendinopathy and implications for rehabilitation.
She continued a postdoctoral project for 3 years from 2012-2015on the effect of physical therapy in
patients with rotator cuff tendinopathy. At present she works in clinic where she is specialized in
shoulder rehabilitation and she teaches scientific methodology in the occupational therapist
education at the Artevelde University College in Ghent, Belgium. Furtheramore she teaches in
international postgraduate courses on shoulder rehabilitation.

Mia Werin

Maya Benzoor

Maya Cale'-Benzoor, PhD, PT. earned her physical therapist diploma in 1981 at Kupat Holim school
of physical therapy at the Wingate institute in Israel. She moved to the US in 1982, to fulfill a dual
mission- training to qualify for the Olympics in track and field, and specializing in sports physical
therapy. After earning a BSc in Physical education from Northern Arizona University in 1984, and
participating in the LA games, further work and studies in Atlanta, GA earned her the advanced
MSc with emphasis on sports injuries. Upon returning to Israel, she began working at the Ribstein
center for sports medicine and research at the Wingate institute, where she currently directs the
physical therapy department. The clinic serves as home for Israeli Olympic athletes, during practice
and competitions. Seeing many top level judokas inspired Maya's current interest in shoulder
rehabilitation and functional exercise progressions. In her PhD thesis, completed in 2007, she
compared CKC rehabilitation through varying ranges of motion in the upper extremity. Maya is
also a lecturer at the University of Haifa Physical therapy program, teaching Kinesiology, sports
injuries rehabilitation and a sports rehab "study in the clinic' course. She has given numerous
talks, presentations and workshops in Israel and abroad, and has several articles published in peer-
reviewed journals. She is on the advisory board of an Israeli start up – PhysiMax, involved in
making motion analysis solutions accessible in the clinic.

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Ann Cools (PhD, PT) is a physiotherapist, working as an associate professor at the Department of
Rehabilitation Sciences and Physiotherapy at the Ghent University, Belgium. After graduation from
the University of Leuven in 1986, she worked in a musculoskeletal physiotherapy practice for several
years. Since 1998, she has a teaching and research assignment at the Ghent University, in basic
education as well as in advanced courses. Her topic of research and teaching expertise, as well as her
clinical work is shoulder rehabilitation in general, and sport specific approach and scapular
involvement in particular. She has published numerous papers in international journals, wrote
contributions and chapters in several international recognized books, and gives courses on a national
and international level. She is at present head of the Physical Therapy Education at the Ghent
University, and was founding member and president of the European Society of Shoulder and Elbow
Rehabilitation (EUSSER) 2008–2012.

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Annelies Maenhout

Maya Benzoor

Mia Werin

Ann Cools

27