Dynamic Chiropractic – March 12, 2010, Vol.

28, Issue 06

Posture Evaluations, Part 1

By Jeffrey Tucker, DC, DACRB

Like you, I keep looking for better ways to help patients out of their ill-health predicaments. Specifically, I look for
that deep meaning of what the person's musculoskeletal system is trying to say to me while I look at their posture.
My hope is to fulfill their expectation of me to improve their life and condition. I've always felt that if I learned enough
about posture and functional anatomy, then my question, "Why does this person have pain?" would be answered.

So much gets revealed to me through posture evaluations. Standing in front of us is a person - usually feeling pain,
loss, fear and anger, and with or without acceptance of the distortions they have become. I understand; I have fear
about losing my ability to be a recreational athlete and move around without pain. The loss of physical function
terrifies me. Looking into the eyes of my patient while I begin to look at their posture creates a "real moment." 

Observing someone walking is what we call gait analysis. Observing someone performing a squat or a lunge is
observing functional anatomy. When I watch someone walk, I see it as the path they have taken in life. When I watch
someone squat, I can write an entire corrective exercise program to improve their functional posture. My intention in
this article series is to paint a picture of what posture can tell us about the muscle system. Think of this series as the
Cliff's Notes for my version of Posture 101.

The most authentic journey of sharing in my chiropractic career occurred this past year. I had the privilege of teaching
an entire postgraduate diplomate course in rehabilitation. My assignment was in San Jose, Calif., and gave me  the
opportunity to teach to one of the brightest groups of young doctors I have ever met. Most participants were certified
in ART and many had other specialty certifications. I realized one thing that has not changed since I was in
chiropractic college: how little doctors really understand posture evaluations! Let's take a look at just some of the
things posture can tell you.

What Posture Can Tell You

Hypertrophied sternocleidomastoid. You will notice a grove medial to the SCM at the angle of the jaw. This
indicates an overactive SCM muscle.
Forward head posture. This indicates posterior weight shift.
Upper extremity internal rotation/round shoulders. This indicates weakness of the middle trapezius; overactive
pectorals, latissimus dorsi, teres major. This may be associated with a fixed thoracic kyphosis.
Rounded shoulders. This indicates overactive pectorals and upper trapezius muscles.
Increased muscle bulk on one side of the forearms. This may indicate the dominant hand side.
Appearance of gothic shoulders. This may indicate overactive upper trapezius and/or be associated with
underactive lower scapular fixators (lower trapezius and serratus anterior).
A bump in the contour of the upper trapezius. This may indicate an overactive levator scapulae muscle.
Scapulae winging. This may indicate an inhibited or underactive serratus anterior muscle.
Flattening of space between medial scapulae border and the spinous processes. This indicates underactive
rhomboids.
Flattening of the fibers of the middle deltoid. This may indicate underactive deltoids.
Flattening of the supraspinatus region. This may indicate an underactive supraspinatus muscle.
Hypertrophied thoracolumbar erector spinae. This may indicate hip extension hypomobility. The thoracolumbar
fascia is a deep investing membrane which covers the deep muscles of the back of the trunk. It is made up of
three layers: anterior, middle and posterior. The anterior layer is the thinnest and the posterior layer is the
thickest. Two spaces are formed between these three layers. Between the anterior and middle layer lies the
quadratus lumborum muscle. The erector spinae muscle is enclosed between the middle and posterior layers.
Above, it passes in front of the serratus posterior superior and is continuous with a similar investing layer on the
back of the neck. In the thoracic region, the lumbodorsal fascia is a thin fibrous lamina which serves to bind
down the extensor muscles of the vertebral column and to separate them from the muscles connecting the
vertebral column to the upper extremity. It contains both longitudinal and transverse fibers and is attached,
medially, to the spinous processes of the thoracic vertebrae; laterally to the angles of the ribs.
 Anterior pelvis tilt (APT). This indicates overactive hip flexors/erector spinae. APT often coincides with forward
head posture. Some of the contributors include poor body mechanics, pregnancy and weight gain. Visual signs
are increased curvature of lumbar region. Palpatory signs are hypertonic (tight) postural musculature including
the iliopsoas, erector spinae, quadratus lumborum and rectus femoris. Pain is often felt in the low back, pelvis,
hips and thighs.  
Pelvis torsion (PI/AS in combination). This indicates a SIJ dysfunction.
Increased lumbar lordosis. This may indicate overactive hip flexors and erector spinae muscles. This may be
associated with underactive/inhibited glute maximus and abdominals. Visually, you may notice that the patient
has a protruding abdomen.
Lateral shift of the pelvis. This is often caused by poor body mechanics when sitting or standing unevenly. The
visual signs are one hip that is higher than the other. Palpatory signs are hypertonic quadratus lumborum
muscle, which is the primary lateral flexor of the low back. Pain is felt on the side where the pelvis is higher, in
the muscle belly and attachment sites. Underactive glute medius is typically found on the anterior ilium side and
is associated with decreased core strength.
Sway back or flat back. Deep, short lumbar lordosis = tight hip flexors and/or erector spinae.
Hip hiking or an elevated iliac crest without rotation. This indicates quadratus lumborum overactivity. The QL is
one of the most commonly overlooked muscular sources of low back pain. It functions as a stabilizer of the
lumbar spine and can act as a hip hiker and a lateral flexor of the lumbar spine.
An underactive gluteus medius muscle. This can be associated with a kinetic chain dysfunction. The knee will
adduct (femur internal rotation), the tibia will abduct, and the navicular drops, causing eversion and a forward
talus. There will be a lengthened posterior tibialis and the set-up for plantar fascitis. Treatment includes
strengthening the glute medius and lengthening the adductors and TFL.
Asymmetrical thigh adductor notching on medial thighs. This may indicate overactive adductors on the side of the
higher notch.
Asymmetrical hamstrings. This may indicate overactive hamstrings. Remember that the adductor magnus can
extend the leg and adduct the leg. Overactivity can lead to SIJ problems. An overactive biceps femoris (short
head) can cause fibula dysfunctions, which leads to ankle dysfunction, which leads to plantar fascitis. The biceps
femoris is easy to evaluate for muscle length. With the patient prone-lying, bend the right hip to 90 degrees. Try
to straighten the leg. Females should be able to get to 90 degrees. Males should be able to achieve 80 degrees.
Less than these benchmarks indicates overactivity and will require stretching.
Altered tone from upper to lower quadrants of recti. This indicates a possible faulty breathing pattern.
Flattened superolateral quadrant of the buttock. A glute maximus asymmetry can indicate inhibited/underactive
gluteals. Check the sacroiliac joints for dysfunction if you observe this. It also indicates possible overactive hip
flexors, and/or rectus abdominus, and/or piriformis muscle.
Absent/decreased VMO. This indicates an inhibited vastus medialis oblique muscle.
Flattening of tibialis anterior muscle. There will be less bulk at the outer quadrant of the shin. This indicates a
possible L5 nerve syndrome.
Groove or prominence of the iliotibial band. This indicates an overactive TFL/ITB. An overactive TFL/ITB may be
associated with a lateral deviation of the patellae.
Flattened heel, flat foot. Hypotonic foot muscles may be due to impaired foot/ankle proprioception; altered
balance between gastrocsoleus and tibialis anterior; impaired knee proprioception (internal knee derangement).
Short, broad Achilles tendon. This indicates overactive gastrocsoleus muscles.
Squared-shaped heel. This indicates posterior weight-bearing.
Pointed-shaped heel. This indicates anterior weight-bearing (rounded heel shape is normal).

Posture Evaluation Guides Treatment Decisions

When I went to chiropractic college in the early '80s, I was taught very little about static posture evaluation. I do
remember being taught to measure the height of the iliac crests; a line across the occipital region and ear lobes; an
imaginary line drawn across the tops of shoulders; and the inferior angle of the scapula. That was about the full extent
of posture assessment. In my own development as a chiropractor, I took the postgraduate diplomate programs in
rehabilitation and started to appreciate visual static anatomy, and later I learned functional anatomy.

Evaluation of static posture is meant to be a screening test. It gives us an initial impression of certain key muscle
imbalances. We will still need to confirm these imbalances with other tests, such as functional movements. Advice
about proper posture is central to treatment. Certainly the initial examination should include the posture assessment. I
think every patient encounter is an opportunity to discuss and fine tune our client's posture. One of the most valuable
pieces of advice is regarding sitting and lifting posture.

When performing a posture assessment, be as accurate as you can and keep chart notes to make your posture
 evaluation a reproducible measurement. Posture evaluations become an objective measurement that can drive
treatment decisions. I perform posture evaluations on every visit because posture can reveal the need for specific
muscle stretching, muscle strengthening requirements and orthotics. That's why I use posture as an outcomes
assessment tool. Improving posture may decrease pain, enhance self-esteem, improve muscle control, improve
performance, provide injury prevention, increase protection and "bracing" for the back, and provide a more stable
center of gravity and a more stable platform for sports movements.

DeJarnette was certainly one of my earliest influences. He described excessive lateral sway in the static posture
evaluation as a sacroiliac joint distortion and excessive P-A sway as a pelvis distortion. Byl in 1991 described
excessive anterior-to-posterior body sway on an unstable surface or poor single-leg-standing balance as correlated
with low back pain. Poor balance has been correlated with future LBP (Takala, 2000).

Patients intuitively understand the value of improved posture, and correcting posture allows them to be part of the
recalibration and treatment process. Taking the time to practice posture evaluations has taught me insights of
immense value in patient care. That's why this series starts with basic principles. In future articles, I will discuss
normal alignment of the body and how the kinetic chain operates as an integrated functional unit.

Dr. Jeffrey Tucker is a rehabilitation specialist, lecturer and healer best known for his holistic approach in supporting
the body's inherent healing mechanisms and integrating the art and science of chiropractic, exercise, nutrition and
attitudinal health. He practices in West Los Angeles and lectures for the National Academy of Sports Medicine and
the American Chiropractic Rehabilitation Board. For more information, please visit www.drjeffreytucker.com.

Page printed from:

http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=54530&no_paginate=true&p_friendly=true&no_b=true
Dynamic Chiropractic – June 17, 2010, Vol. 28, Issue 13

Posture Evaluations, Part 2: Forward Head and Forward

Shoulder
By Jeffrey Tucker, DC, DACRB

According to Dr. Al Sears, muscle is the first physical sign of aging, in the sense that people who age well are often
well-muscled, which protects them from age-related ailments including pain and disease. I think this is correct, but I
would add that I think one of the first physical signs of aging is also poor posture. Forward head carriage is
observed when the chin goes forward. From my experience, when the head starts to go forward (anterior shift),
people start to look older. Prolonged sitting can cause muscle imbalances in the neck and shoulder that lead to the
"poked chin" posture. Once forward head posture starts, the shoulders may start to round, thoracic kyphosis becomes
accentuated, the sacral base may shift, and/or the pelvis distorts. The end result: occipital misalignment.

Evaluating Posture Distortions

I know that evaluating forward head posture leads to one of those "chicken and egg" questions. Is it ascending or
descending; from top to bottom or bottom to top? Sometimes I know the answer and sometimes I have to guess. I
just look for patterns and sequences of how all this stuff works together in my patient's big picture. For example, have
them sit on a chair or a stool; observe from the side as they sit down and stand up. Watch the head and neck area
only. The normal pattern is for them to lead with the posterosuperior aspect of the head. If the SCMs and
suboccipitals are dominating, they will lead with the chin. This is a faulty pattern.

Follow the logic of forward head posture and forward shoulder posture. It may be associated with underactive,
lengthened, inhibited deep cervical flexors, lower trapezius and serratus anterior; or overactive, facilitated
suboccipitals (longus coli, capitus), upper trapezius, levator scapulae, SCM and pectoralis muscles. Janda described this
muscle imbalance pattern as the upper crossed syndrome.

You can correlate this information with standing and sitting palpation. If you observe a forward head in the standing
posture, palpate and assess the patient's suboccipital muscle tension. Then have them sit down. If tension in the
suboccipital area subsides, the forward head may be secondary to forward-drawn posture from the pelvis. Sitting
down takes the pelvis out of the equation.

Sometimes there is a temporomandibular component causing a forward head posture. This is called a descending
process and goes something like this: When airway space is compromised, the body moves the head into a forward
position, opening up the airway space. This can cause a hyperlordotic upper cervical region and a straightened or
reversed lower cervical curve. This may ultimately cause the whole suboccipital musculature to contract. The visual
righting mechanism compensates for this by bringing the head forward, which also opens the airway along with the
suboccipital contraction.

Forward head posture is multifactorial and may sometimes necessitate dental cooperation. Sacro-occipital technique
(SOT) integrates cranial adjustments with dental interventions to help make proper corrections. In addition, sleep
issues are pandemic and airway issues are also present. And when patients have overactive suboccipital muscles and
the upper cervicals are fixed or out of alignment, there is an association with cervicogenic headaches and other related
complaints.

Corrective Rehab Strategies

Corrective exercise/rehab strategies try to improve the muscle imbalances and joint motion. In doing so, the forward
head posture can be corrected if the compensatory patterns are not too severe. Instructions to patients include
postural awareness so they stop the faulty repetitive action during sitting, standing, sleeping and talking. Get them
aware of how they are sticking their chin forward, which changes the relationship of the head to the torso.

Another suggestion is to teach them proper alignment of the feet while standing. Proper alignment of the feet includes
 "grounding" or "rooting" though the four corners of the feet (the big toe mound, the baby toe mound, the inner heel
and the outer heel). Equal weight distribution on these areas lifts the arches and equally distributes weight between
each foot. Tell patients to keep constant and equal weighted contact through these points to get "grounded" and to
think of the roots of a tree. Notice if lifting the toes toward the nose while standing helps to activate the foot muscles
and lift the arches. Also, telling your patients to maintain a "tall spine'"while they are standing and walking is easily
understood and helps improve forward head posture.

Have you ever noticed that when you ask one of your older patients to get up from the table or a chair, they are often
walking before they fully straighten up? Most of us do that to some degree. Just observe others or yourself when you
are in a rush.

Also think about how many children are in school working with their heads down, and how many people have their
computer monitor or keyboard tray at the wrong level. Our computer lifestyle promotes overactivity of the pectoralis
minor, while the mid-lower trapezius muscles become lengthened. The rhomboids and serratus become inhibited as
well. This imbalance causes a gradual rounding of the shoulders, resulting in a change in thoracic 4 segment. T4
dysfunction often occurs with head forward / round shouldered posture. It arises most often from muscle length-
tension relationship imbalance and force-couple relationships.

Corrective exercise strategies taught by the National Academy of Sports Medicine for forward shoulder posture and
forward head posture include balancing upper-body muscle length-tension relationships and developing good strength.
Specific corrections for forward head posture include inhibiting and lengthening the levator scapula, upper trapezius,
SCM and suboccipital muscles. Activate the deep neck flexors with chin tucks, and teach the patient whole-body
exercises like the prone ball cobra.

The whole-body approach to abnormal forward shoulder posture is to check for a thoracolumbar hypertrophy and
swayback alignment. A swayback decreases the demands of the hip extensors. The gluteals may appear
underdeveloped and usually test weak manually. People who stand in a forward-leaning posture have greater demand
on the gastrocsoleus muscle and less demand on the anterior tibialis. A person with a supinated rigid foot (a high
instep) may have a line of gravity that is more toward the rear of the foot and tend to use the anterior tibialis muscle
to bring the body forward. This person has a tendency to develop anterior shin splints.

Specific correction includes inhibiting and lengthening the levator scapulae, upper trapezius, pectoralis muscles, and
latissimus dorsi. Some simple post-isometric relaxation exercises or self-stretching of these muscles, alternating with
rhomboid muscle "squeezes" to effectively strengthen the rhomboid and improve the T4 dysfunction, will help restore
shoulder and head posture. Also, activate the mid/lower trapezius with prone abduction and scaption exercises.
Activate the teres minor and infraspinatus muscles with side-lying external rotation exercises. Use squat-to-row
maneuvers and "push-ups with a plus" as a whole-body exercise.

Keep in mind that for all postural corrections, you cannot omit the inhibition component (foam roll) and only perform
stretches, and you cannot omit stretching and just perform soft-tissue techniques. A combination exercise/rehab
approach is best to correct forward head or forward shoulder posture.

Dr. Jeffrey Tucker is a rehabilitation specialist, lecturer and healer best known for his holistic approach in supporting
the body's inherent healing mechanisms and integrating the art and science of chiropractic, exercise, nutrition and
attitudinal health. He practices in West Los Angeles and lectures for the National Academy of Sports Medicine and
the American Chiropractic Rehabilitation Board. For more information, please visit www.drjeffreytucker.com.

Page printed from:

http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=54719&no_paginate=true&p_friendly=true&no_b=true
Dynamic Chiropractic – August 26, 2010, Vol. 28, Issue 18

Posture Evaluations, Part 3: The Shoulder and Scapula

By Jeffrey Tucker, DC, DACRB

Editor's note: Part 1 of this article ran in the March 12, 2010 issue; part 2 appeared in the June 17, 2010 issue.

Let's discuss normal shoulder resting posture so we can determine if there is a link between a postural deviation and
pain. Static postural analysis is performed before range-of-motion examinations, orthopedic testing, movement
pattern assessments and palpation analysis. When I perform a static posture evaluation, I focus on subtle
asymmetries or deviations from normal patterns to aid my diagnostic decisions and treatment transition decisions
(passive care to active therapy). I allow myself the time to pause and focus on what I see posturally before beginning
other procedures. The changes I see in static posture and functional-movement assessments, visit to visit, help me
navigate through the treatment process.

I ask the patient to stand with their shoes off, hands at their sides, in their normal, relaxed position. The evaluation is
done with the person in a standing position, which accounts for the normal effect of gravity on the individual. I
observe the patient from the front, side and posterior. I look to see the person's chronic holding patterns.

Look for postural deviations, including forward head, forward shoulders (scapular protraction), humeral internal
rotation, and increased thoracic kyphosis. All of these deviations have been implicated in the development of shoulder
pain.1-4

An abnormal posture or chronic holding pattern may change the muscle system's ability to produce precise movement,
and over time or with exposure to repetitive tasks, will cause pain to develop as a response to these imprecise
movements.5 Abnormal changes in 1) muscle balance and strength (length-tension relationships), 2) muscle
recruitment (force couple relationship) timing issues and 3) articular joint motion dysfunction can cause increased
scapular internal rotation, decreased scapular posterior tilting, and decreased scapular upward rotation, leading to
subacromial impingement syndrome and other shoulder pathology.6-8

Combining static observation of the scapula, glenohumeral position

and thoracic kyphosis with shoulder range-of-motion examination
Quick Review of Shoulder Muscle Action
and movement pattern assessments will help you detect alterations
causing shoulder pain and pathology. For example, an overactive
1. Shoulder’s medial rotators: Subscapularis
pectoralis minor muscle will cause the scapula to tilt anterior. An
and pectoralis minor (tilts)
underactive serratus anterior will not rotate the scapula properly,
2. Shoulder’s external rotators:
and an underactive lower trapezius will not depress the scapula
Infraspinatus and teres minor
properly. Any of these will contribute to a decrease in the
3. Supraspinatus (abducts, laterally rotates)
subacromial space by failing to move the acromion away from the
assisted by the deltoid (abducts) and
humeral head during arm elevation, resulting in increased
infraspinatus (lateral rotator)
compressive loads on the tendons of the rotator cuff or long head of
4. Lower trapezius, primary scapular
the biceps muscle. 9-10 depressor.

After you have looked at the thoracic curve, look at the humeral
head. Normally, the body of the humeral head should be approximately one-third forward of the AC joint. Normally,
when the patient's arms are at their side, the humerus should be in neutral rotation and the olecranon process should
face posteriorly. The thumbs should be pointing straight ahead (forward) and the palms should be facing each other.

Next, look at the scapula. The scapulae function in three dimensions. The scapulae tilt forward and backward,
rotate inward and outward, and rotate upward and downward. Without proper trunk alignment, it is impossible to
have proper alignment of the scapulae. Due to the position of the scapula on the rib cage, the scapula is "offset" 30
degrees to the frontal plane.6 This position allows for the necessary "safe" motion of the shoulder. Looking down from
 the head, a forward or protracted scapula is more than 30 degrees forward, and a retracted scapula is less than 15
degrees forward.

Carefully look at the scapular alignment itself. Normal or "scapular neutral" features the following characteristics:

Ideal scapular plane is approximately 15 to 30 degrees forward of the coronal plane.

Medial border of the scapula should be approximately parallel or upwardly rotated to the spine (the inferior angle
should be lateral to the superior medial border).
Medial border is approximately 2 to 3 inches from the spinous process.
Medial edge of the spine of the scapulae is level with T3 and projects to T4.
AC joint should be about 1 inch higher than the SC joint.
Coracoids should be symmetrical.
Clavicles should be symmetrical and incline slightly upward.
Scapulae should lie flat against the rib cage. 6,11

After visual analysis, use your hands to feel and "listen" to the scapular controlling muscles: serratus anterior,
rhomboids, upper trapezius, levator scapulae, middle/lower trapezius, and pectoralis minor.

The practice of being a "muscle whisperer" using posture analysis, guiding manipulation, self-directed soft-tissue
release work (foam roll), static stretching, dynamic self-mobilization and strength training can create extraordinary
posture changes that improve the function of the scapulothoracic and glenohumeral joints. In an upcoming article, I
will discuss identification of the winged scapula and rehab exercises for this condition.

References

1. Finley MA, Lee RY. Effect of sitting posture on 3-dimensional scapular kinematics measured by skin-
mounted electromagnetic tracking sensors. Arch Phys Med Rehabil, Apr 2003;84(4):563-8.
2. Greenfield B, Catlin PA, Coats PW, et al. Posture in patients with shoulder overuse injuries and healthy
individuals. J Orthop Sports Phys Ther, May 1995;21(5):287-95.
3. Griegel-Morris P, Larson K, Mueller-Klaus K, Oatis CA. Incidence of common postural abnormalities in the
cervical, shoulder, and thoracic regions and their association with pain in two age groups of healthy
subjects. Phys Ther, June 1992;72(6):425-31.
4. Kebaetse M, McClure P, Pratt NA. Thoracic position effect on shoulder range of motion, strength, and
three-dimensional scapular kinematics. Arch Phys Med Rehabil ,May 1999;80(8):945-50.
5. Kendall FP, McCreary EK, Provance PG. Muscles: Testing and Function (4th Edition). Baltimore: Williams &
Wilkins, 1993.
6. Sahrmann SA. Diagnosis and Treatment of Movement Impairment Syndromes. St Louis: Mosby, 2002.
7. Sahrmann SA. Does postural assessment contribute to patient care? J Orthop Sports Phys Ther, Aug
2002;32(8):376-9.
8. Lukasiewicz AC, McClure P, Michener L, et al. Comparison of 3-dimensional scapular position and
orientation between subjects with and without shoulder impingement. J Orthop Sports Phys Ther, Oct
1999;29(10): 574-83.
9. Ludewig PM, Cook TM. Alterations in shoulder kinematics and associated muscle activity in people with
symptoms of shoulder impingement. Phys Ther, Mar 2000;80(3):276-91.
10. Hebert LJ, Moffet H, McFadyen BJ, Dionne CE. Scapular behavior in shoulder impingement syndrome. Arch
Phys Med Rehabil, Jan 2002;83(1): 60-9.
11. Comerford M. Kinetic control shoulder lecture notes.

Dr. Jeffrey Tucker is a rehabilitation specialist, lecturer and healer best known for his holistic approach in supporting
the body's inherent healing mechanisms and integrating the art and science of chiropractic, exercise, nutrition and
attitudinal health. He practices in West Los Angeles and lectures for the National Academy of Sports Medicine and
the American Chiropractic Rehabilitation Board. For more information, please visit www.drjeffreytucker.com.

Page printed from:

http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=54845&no_paginate=true&p_friendly=true&no_b=true
Dynamic Chiropractic – October 21, 2010, Vol. 28, Issue 22

Posture Evaluations, Part 4: Winged Scapula

By Jeffrey Tucker, DC, DACRB

Editor's note: Part 1 of this article ran in the March 12, 2010 issue; part 2 appeared in the June 17, 2010 issue; and
part 3 ran in the Aug. 26 issue.

Most of the time when we think of a winged scapula, we simply think of weak serratus anterior muscles. But the
longer you are in practice, the more you notice posture and become a better "muscle whisperer." And then you begin
to realize so much more. Let's explore the posture impairment of winged scapula as it relates to the serratus
anterior, rhomboids, lower trapezius, and pectoralis muscles.

The biggest tip I can offer you to look for during static posture evaluation for scapular winging is this: If you can see
the entire medial border of the shoulder blade, you should suspect serratus anterior dysfunction. If you see only a
portion of the medial scapular border or the inferior angle (usually the lower half or third of the medial scapula
border), then you should suspect excessive shortness of the pectoralis minor, and lower trapezius and serratus
anterior muscle weakness dysfunction. Again, if you only see half or a third of the scapula border protruding away
from the rib cage, this is known as "pseudo-winging" and implicates shortness of the pectoralis minor, along with
lower trapezius and serratus anterior underactivity or weakness.

While looking at the scapula, ask yourself if you see a forward shoulder. During static posture evaluation for forward
shoulder posture, check for sagittal plane or transverse plane scapular resting position change. This change should
make you think of adaptive shortening of the pectoralis minor muscle due to approximating the muscles' insertion
sites on the coracoid process and ribs three, four and five.

Next, perform movement assessments to determine if we are dealing with true "winging" (serratus anterior) or
"pseudo-winging" (lower trapezius). Here are three simple movement assessments to determine scapular winging:

Ask the patient to raise both arms from their sides (palms facing each other). Observe the scapula from behind.
During concentric elevation of the arms, you should notice prominence of the entire medial scapular border.

Ask the patient to lower their arms from the overhead position (palms facing each other). Observe the scapula
from behind. During eccentric lowering of the arms, you should notice prominence of the entire medial scapular
border.

Patient position: Push-up position (either against a wall or with palms on the floor with knees locked or with
knees on the floor). Men can have shirts off, women can have a sports bra on. Notice the scapula during the up-
and-down move. If the patient has a winged scapula (prominence of the entire medial scapular border) the
shoulder blade will stick out; this means the serratus anterior is weak. A strong serratus suctions the scapula in
during the movement, eliminating the winged look.

It is important to know the proper muscle function of the pectoralis minor, rhomboid, serratus anterior, and lower
trapezius because these muscles control scapular motion. The normal resting muscle length of the serratus
anterior, pectoralis minor and lower trapezius allows the scapula to stay placed against the rib cage. The rhomboid
muscles adduct and downwardly (medially) rotate the scapula. The serratus anterior allows you to abduct and
upwardly (laterally) rotate your scapula when you raise your shoulder to flex your arm and move it away from your
body.

Tom Meyers has described a direct fascial connection from the rhomboid to the medial border of the scapula into the
serratus anterior; hence, he calls this the rhombo-serratus muscle. He suggests that these two muscles work
together. A decreased pectoralis minor muscle resting length would result in an increase in the muscles' passive
tension during arm elevation, restricting normal scapular upward rotation, posterior tipping and external rotation.
 Patients with shorter or overactive pectoralis minor muscle resting length demonstrate increased scapular internal
rotation during arm elevation and decreased scapular posterior tilting at higher arm elevation angles (90 degrees and
120 degrees) when compared with a group of subjects with a relatively longer pectoralis minor muscle resting length.
The importance of understanding these muscle relationships is that any faulty muscle control can cause shoulder
impingement.

Resources

Ludewig PM, Cook TM. Alterations in shoulder kinematics and associated muscle activity in people with
symptoms of shoulder impingement. Phys Ther, 2000;80:276 -291.
Borstad JD, Ludewig PM. The effect of long versus short pectoralis minor resting length on scapular kinematics
in healthy individuals. J Orthop Sports Phys Ther, 2005;35(4):227-38.
Sahrmann SA. Diagnosis and Treatment of Movement Impairment Syndromes. St Louis, Mo: Mosby; 2002.
Sahrmann SA. Does postural assessment contribute to patient care? J Orthop Sports Phys Ther,
2002;32:376 -379.
Hebert LJ, Moffet H, McFadyen BJ, Dionne CE. Scapular behavior in shoulder impingement syndrome. Arch
Phys Med Rehabil, 2002;83: 60-69.
Myers TW. Anatomy Trains. Churchill Livingstone; 2001.
Comerford & Kinetic Control class notes, 2006.

The follow-up article to this one will describe a corrective exercise strategy for scapular winging.

Dr. Jeffrey Tucker is a rehabilitation specialist, lecturer and healer best known for his holistic approach in supporting
the body's inherent healing mechanisms and integrating the art and science of chiropractic, exercise, nutrition and
attitudinal health. He practices in West Los Angeles and lectures for the National Academy of Sports Medicine and
the American Chiropractic Rehabilitation Board. For more information, please visit www.drjeffreytucker.com.

Page printed from:

http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=54964&no_paginate=true&p_friendly=true&no_b=true
Dynamic Chiropractic – December 16, 2010, Vol. 28, Issue 26

Posture Evaluations, Part 5: A Corrective Exercise Strategy for

Scapular Winging
By Jeffrey Tucker, DC, DACRB

I have yet to meet a chiropractor who is not looking for a universally applicable step-by-step treatment approach to
help patients reclaim and transform numb, tingling, tight, stiff or painful body parts so they can feel, in each moment,
wholeness and well-being. However, after 28 years in practice, I don't think there is such a step-by-step treatment
approach. I think we develop individual treatment approaches or processes depending on the chiropractor, the patient
and the circumstances.

My current treatment approach includes using manipulation/mobilization, warm laser, deep muscle stimulator, fascial
release, foam rolling, stretching, muscle activation, core work, and whole-body exercises (often utilizing bands and
kettlebells). In the past four articles, I discussed looking more closely at static posture to see what this reveals to
assist in our clinical decision process. In the last article, I presented information we can use to look at the shoulder
during a static posture evaluation. Now let's connect what we see in the winged scapula to the corrective exercise
strategies we can prescribe for this dysfunction. Please keep in mind that the best exercise you select for your client is
the exercise that produces carryover, meaning it improves movement capacity and movement quality, in this case of
the scapula.

Postural Analysis of Scapular Winging

Static postural analysis may reveal scapular winging. However, I use many tests to determine what the scapula is
doing functionally. Let's consider some possible scenarios:

Winging may be noted during glenohumeral joint flexion.

Winging may be noted during glenohumeral joint abduction/elevation.
Winging may be noted during the return from glenohumeral joint elevation, most notably during the first half of
the movement from 180 degrees to extension.
Winging of the entire medial scapula border may be noted on the push-up "plus" movement pattern test
challenge.
If you see scapular winging in the static posture evaluation, have the patient elevate the arm maintained in
external rotation. Elimination of scapula winging confirms posterior instability.
The scapula is also probably winging if you get stuck in the bottom position on the bench press, in which case
you need serratus anterior strengthening work. (This can be accomplished with military press work and incline
front raises.)

Scapular winging during any of these movement assessments indicates a mechanical defect of an underactive serratus
anterior (SA), a long serratus anterior nerve dysfunction or a motor coordination problem. The SA is considered a
global stability muscle of the scapula. The serratus originates on the profound side of the medial border of the scapula
and passes to attachments on the first nine ribs. The serratus pulls the scapula inferiorly and laterally; the rhomboids
pull the scapula superiorly and medially. A chronically shortened or overactive serratus will pull the scapula wide on
the posterior rib cage, causing the rhomboids to be strained long. This pattern frequently accompanies a kyphotic
thoracic spine.

A winged scapula is often associated with overactive pectoralis minor muscle length. A short pectoralis minor muscle
(a common postural finding) pulls the scapula forward and down by tilting the scapula anteriorly. The corocoid process
moves anteriorly and inferiorly and the inferior angle of the scapula moves posteriorly. It produces medial rotation of
the scapula (downward rotation of the glenoid). This explains how the overactive pectoralis minor muscle alters the
scapular movement. Palpation of the pectoralis minor muscle will demonstrate tenderness if it is overactive. The
shortening of the pectoralis minor is related to SA and trapezius muscle imbalance. This imbalance is one scenario
responsible for patients with impingement syndrome. Part of the scapular winging treatment plan is correcting the
muscle length-tension of pectoralis minor.
Exercises to Improve Scapular Winging

If there were a set program for all scapular winging patients, we would have found it by now and scapular winging
would be rare. I suggest you use some of these exercises as a base, observe the response over a couple of weeks and
act accordingly. Teaching awareness of proper scapular position is first. Train normal scapular alignment in the seated,
standing, wall lean and quadruped positions.

Push-Up / Serratus Plus: The "push-up plus" or "serratus plus" seems to be the most popular exercise used to
strengthen the SA muscle. To properly perform this exercise, the patient needs to know these tweeks: 1) In the push-
up position, place the thumbs together. 2) Lift the hands slightly above shoulder height (the hands should be under
the eyes) and add slight internal rotation. 3) Just move the shoulder blades, don't move the head or drop the hips. 4)
Push the scapula apart, let gravity push them back together again, push the scapula apart (that is one repetition). If
the patient can't get into a push-up position, start them out on the forearms.

In my experience, doing "push-up plus" variations is the quickest way to correct a weakness. For example, progress
to reaches from prone-on-elbows; reaches from a plank position cause more weight to shift into the SA and cause
reflex stabilization. Moving from prone-on-elbows to the start position of a push-up also has deep developmental
roots from a sensory standpoint. I like to have patients perform a downward dog (yoga position) and add a push-up
plus between each downward dog. This helps produce stabilization through better perception in the core and shoulder
girdle.

Band or Cable Chops and Lifts. The chop is performed by attaching tubing or a cable at a high point of attachment and
holding both handles. Kneel at an outward angle with the outside knee down. Both knees should be flexed at 90
degrees. The patient should narrow their base to within 6-inch width of knee of one leg and heel of the other. Hold
hips directly under the trunk and spine erect with the shoulders back and scapula properly placed. Arms should be
extended with palms facing together while holding the handles. Pull the tubing down and across the chest while
keeping it close to the body. Shoulders should turn minimally and the head should face forward. All actions should be
done with the arms. The tubing should come across the body from shoulder to opposite hip, palms facing down.
Tubing should be in line with the closest arm. Before starting the exercise, make sure the scapula are set properly.

The lift is performed with the tubing at a low point of attachment. The patient should grab both handles and kneel at
an outward angle with inside knee down. Both knees should be flexed at 90 degrees.

Incline Push-Ups: Use a power rack to perform incline push-ups on a barbell. Patient should start with the body at the
lowest incline that doesn't allow their shoulders to wing, which means placing the bar relatively high. Perform three
sets of between eight and 12 repetitions. As they become stronger and learn to control their scapular motion, they
can work their way down the rack until they're doing regular push-ups with perfect body alignment.

Serratus Punches: I have prescribed serratus punches in the supine position, the standing position, with hand weights,
without hand weights, with tubing and with cable. This is one exercise you just have to tinker with until it achieves the
desired effect of activating the SA.

Shoulder Scaption: Every chiropractor should know shoulder scaption because it has such overall benefits for all
kinds of shoulder conditions. Holding a light pair of dumbbells (1-5 lbs), the patient stands with the arms in the
scapular plane with the thumbs down. As the arms are raised, they begin to rotate externally (thumbs begin to rotate
outward). By the time the arms are at shoulder level, the thumbs should be facing up. The elbows stay straight
throughout the exercise.

Two other reminders: Instruct your patients to avoid slumped postures and use manipulation to the mid-upper
thoracic spine fixations.

Resources

1. Kendall FP, McCreary EK, Provance PG. Muscles: Testing and Function,.4th Edition. Baltimore, MD: Williams &
Wilkins; 1993.
2. Sahrmann SA. Diagnosis and Treatment of Movement Impairment Syndromes. St Louis, MO: Mosby; 2002.
3. Ludewig PM, Cook TM. Alterations in shoulder kinematics and associated muscle activity in people with symptoms
of shoulder impingement. Phys Ther, 2000;80:276-291.
4. Borstad JD, Ludewig PM. The effect of long versus short pectoralis minor resting length on scapular kinematics in
healthy individuals. JOSPT, April 2005;35(4):227-38.
 Editor's note: Part 1 of this article ran in the March 12, 2010 issue; part 2 appeared in the June 17, 2010 issue; part
3 ran in the Aug. 26 issue; and part 4 appeared in the Oct. 21 issue.

Dr. Jeffrey Tucker is a rehabilitation specialist, lecturer and healer best known for his holistic approach in supporting
the body's inherent healing mechanisms and integrating the art and science of chiropractic, exercise, nutrition and
attitudinal health. He practices in West Los Angeles and lectures for the National Academy of Sports Medicine and
the American Chiropractic Rehabilitation Board. For more information, please visit www.drjeffreytucker.com.

Page printed from:

http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=55067&no_paginate=true&p_friendly=true&no_b=true