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Integrated functional anatomy of the subscapularis (rotator cuff). Attachments, nerves, palpation, joint actions, arthrokinematics, fascia, triggerpoints, and behavior in postural dysfunction. Common exercises, foam rolling, injury prevention, and stretches of the rotator cuff.

Subscapularis

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Human Movement Specialist

This course describes the anatomy and integrated function of the subscapularis, which is 1 of 4 rotator cuff muscles (a.k.a. SITS muscles). Sometimes referred to as the anterior rotator cuff, the subscapularis originates from a depression that covers the majority of the anterior surface of the scapula (shoulder blade), known as the subscapular fossa. The subscapularis courses distally into the subscapularis tendon which inserts into the the superior and medial aspect of the lesser tubercle of the humerus and capsule of the glenohumeral (shoulder) joint. The subscapularis occupies its own fascial compartment, covered by a fascial sheath that may be a continuation of the axillary fascia and serratus anterior fascia by coursing medially, investing in the medial border of the scapula, and then folding back over itself covering the subscapularis. Research suggests that the subscapularis is a relatively large upper body muscle, contributing to approximately 6.6% of the total upper body muscle mass (for comparison, the pectoralis major contributes approximately 10%), and the subscapularis is the largest rotator cuff muscle (the infraspinatus is the 2nd largest rotator cuff muscle). Additionally, research suggests that the subscapularis is composed of only about 20 - 40% type I muscle fiber (4, 5).

The subscapularis muscle crosses the shoulder (glenohumeral) joint and contributes to internal rotation, adduction, and shoulder stabilization. This course also describes the role of the subscapularis on shoulder (glenohumeral) arthrokinematics, fascial integration, subsystem integration, and postural dysfunction. For example, the subscapularis may act synergistically with the latissimus dorsi, pectoralis major, and teres major to contribute to internal rotation and inferior glide of the humeral head in the glenoid fossa. If these actions occur excessively due to muscle over-activity, they may be a component of the sign "

postural dysfunction (e.g. movement impairment) of the upper body.

Sports medicine professionals (personal trainers, fitness instructors, physical therapists, massage therapists, chiropractors, occupational therapists, athletic trainers, etc.) must be aware of the 

 function of the subscapularis for detailed assessment and analysis of human movement, and the development of sophisticated exercise programs and therapeutic (rehabilitation) interventions. For example, altered activity and length of the subscapularis may contribute to rotator cuff injury, rotator cuff tears, shoulder pain, shoulder conditions, shoulder impingement syndrome (SIS), biceps tendon impingement and the resulting weakness and pain during motion such as external rotation and internal rotation. Altered subscapularis activity may also result in a reduction in infraspinatus and teres minor activity, resulting in a significant reduction in upper body speed, agility, and strength, and a reduction in the effectiveness of resistance training intended to improve upper body strength and hypertrophy (bodybuilding). Deeper knowledge of subscapularis anatomy is essential for optimal assessment, intervention selection, and building a repertoire of subscapularis specific techniques.

Sample Intervention: Loss of Shoulder Range of Motion

Subscapularis (and Pectoralis Major and Minor) Static Stretch

Shoulder External Rotation Isolated Activation

Squat to Row (Posterior Oblique Subsystem)

Brookbush Institute’s most recommended techniques for the Subscapularis (see videos below):

Dynamic Pec (Pectoralis Major and Minor) Subscapularis Stretch

A cadaver dissection of the subscapularis muscle of the rotator cuff

 Course Description: Subscapularis

Subscapularis Course Study Guide

Study Guide: Subscapularis

Webinar: Subscapularis

Introduction

 1794, intransitive, back-formation from 

. Transitive sense from 1823. Related: Rotated; rotating. Rotator “muscle which allows a part to be moved circularly” is recorded from the 1670s. (

 “bottom of a sleeve,” mid-14c., cuffe “hand covering, mitten, glove,” perhaps somehow from Medieval Latin cuffia “head covering,” of uncertain origin. Sense of “band around the sleeve” is first attested 1520s; sense of “hem of trousers” is 1911. (

An image of the rotator cuff muscles and shoulder joint 

https://upload.wikimedia.org/wikipedia/commons/thumb/f/fc/Shoulder_joint.svg/402px-Shoulder_joint.svg.png

 word-forming element meaning "under, beneath; behind; from under; resulting from further division," from Latin preposition sub "under, below, beneath, at the foot of," also "close to, up to, towards;" of time, "within, during;" figuratively "subject to, in the power of;" also "a little, somewhat" (as in sub-horridus "somewhat rough"). (

 "shoulder blade," 1570s, Modern Latin, from Late Latin scapula "shoulder," from Latin scapulae (plural) "shoulders, shoulder blades," perhaps originally "spades, shovels," on notion of similar shape, but animal shoulder blades might have been used as scraping tools in primitive times, from PIE *skap-, variant of *skep- "to cut, scrape" (see 

: word-formation element meaning "about, of the nature of," from Latin -arem, -aris "of the kind of, belonging to," a secondary form of -alis, dissimilated form used after syllables with an -l- (such as insularis for *insulalis, stellaris for *stellalis) (

"Belonging to the underside of the scapula"

The attachment of the subscapularis on the scapula

By Henry Vandyke Carter - Henry Gray (1918) Anatomy of the Human Body (See "Book" section below) Bartleby.com: Gray's Anatomy, Plate 202, Public Domain, https://commons.wikimedia.org/w/index.php?curid=307340

Etymology of Terms Related to the Subscapularis

Attachement & Innervation: Subscapularis

 The proximal attachment invests in the majority of the anterior surface of the scapula, filling a depression known as the subscapular fossa, from the vertebral border to the axillary border (1).

The distal attachment invests in the lesser tubercle of the humerus and joint capsule (1,2).

This muscle is innervated by both the upper and lower subscapular nerve, arising from the posterior cord of the brachial plexus via the ventral rami of nerve roots C5 and C6, and occasionally C7 (2, 3).

While the upper subscapular nerve innervates the subscapularis directly, the lower subscapular nerve divides into two branches, with one branch innervating the lower part of the subscapularis and the other innervating the teres major. The middle subscapular nerve is also known as the thoracodorsal nerve and innervates the 

Subscapularis Relative Size and Muscle Fiber Type:

The subscapularis is a moderately sized muscle, contributing approximately 6.6% of the total muscle mass of the muscles in the upper body. In comparison, the pectoralis major muscle contributes approximately 10.7% (4).

Two studies demonstrate that the subscapularis is primarily type II muscle fibers, and is composed of only 20 - 40% type 1 muscle fibers (5, 6).

The upper, middle, and lower subscapular nerves innervating the subscapularis

Note the course of the upper, lower and middle subscapular nerves - http://med.uc.edu/labmanuals/GA%20(2009-10)/UPPER%20EXTREMITIES/UPPER%20EXTREMITIES%20EDITED_files/image016.jpg

Relative Location

The subscapularis lies between the anterior surface of the scapula and the ribcage. It originates from the majority of the anterior surface of the scapula, filling a depression known as the subscapular fossa, from the vertebral border to the axillary border. The origin and the majority of the body of the subscapularis abuts the 

 anteriorly, although these muscles are separated by several layers of fascia, and the subscapularis bursa. The thoracodorsal (middle subscapular) nerve exits the posterior cord of the brachial plexus, passing through the axilla, and descends between the anterior surface of the subscapularis and 

. The upper subscapular nerve and lower subscapular nerve arise from the thoracodorsal nerve to innervate the subscapularis.

The distal tendon of the subscapularis inserts into the lesser tubercle. In route to the lesser tubercle, the subscapularis tendon emerges posterior to the 

, coursing deep to the proximal attachment of the short head of the biceps brachii. A neurovascular bundle from the brachial plexus containing most of the nerves and blood flow for the arm, passes between the pectoralis minor and subscapularis tendons. Further, the subscapularis tendon continues to blend with the fascial web of the anterior capsule, superior and middle glenohumeral ligaments, coracohumeral ligaments, the transverse humeral ligament, and the periosteum of the lesser tubercle.

The insertion of the subscapularis on the lesser tubricle of the humerus

Insertion of Rotator Cuff Muscles - Note the yellow represents articular cartilage and the black is the insertion of the teres minor - http://image.slidesharecdn.com/cordasco

Where is the Subscapularis Located?

Palpation

Palpating the Subscapularis (from the axilla)

Ask your partner to assume a supine position.

Cradle their arm and gently pull the scapula into as much protraction as you can, with some shoulder flexion to promote upward rotation of the scapula. You want as much of the anterior surface of the scapula pulled away from the rib cage as can be maintained comfortably.

Use the thumb of the other hand to palpate the subscapularis. You can access the subscapularis by following the rib cage down into the anterior face of the scapula, which should now be exposed by positioning the arm as directed in Step 1. If you press down (toward the table) into the posterior wall of the axilla, you may not feel the thinner fibers of the subscapularis, but you will note a mass of tissue covering the solid scapula. This mass of tissue is the subscapularis, and having your partner gently internally rotate their arm (no adduction) will cause the subscapularis fibers to contract and move while becoming more dense under your fingers.

Alternate Palpation (from the medial border of the scapula)

Ask your partner to assume a side-lying position.

Either cue or manually move the scapula into protraction and potentially elevation (anterior tipping).

Identify the "triangle of auscultation" by locating a small triangular-shaped area just medial to the inferior angle of the scapula where there seem to be no muscles covering the rib cage. The lack of muscular attachments will allow you to curl your fingers under the medial aspect of the inferior angle of the scapula.

Once your fingers are under the inferior angle of the scapula, you can retract the scapula over your curled fingers. You can then explore the anterior surface of the scapula and the muscle belly of the subscapularis

Alternating relaxation and contraction of the subscapularis via resisted shoulder internal rotation may aid in identifying the muscle belly as it contracts under your fingers.

Palpating the Subscapularis

Actions

The subscapularis will contribute to internal rotation and adduction of the shoulder (7-10).

The subscapularis is the largest rotator cuff muscle, and will contribute to stabilization of the glenohumeral joint during all joint actions.

The subscapularis eccentrically decelerates external rotation and abduction of the shoulder.

: During shoulder internal rotation, the latissimus dorsi is the prime mover, and the subscapularis is a synergist along with the pectoralis major, anterior deltoid, and teres major.

: During shoulder adduction, the latissimus dorsi is the prime mover, and the subscapularis is a synergist along with the pectoralis major, coracobrachialis, and teres major.

As part of the rotator cuff musculature, the subscapularis, supraspinatus, infraspinatus, and teres minor contribute synergistically to dynamically stabilize the glenohumeral joint.

Subscapularis Colored Purple - https://classconnection.s3.amazonaws.com/751/flashcards/2200751/jpg/11351644299147.jpg

Arthrokinematics

The deltoid and rotator cuff muscles direction of force on the shoulder joint

Subscapularis Muscle Actions

Fascial Integration

Our understanding of fascia has benefited from an exponential increase in research over the past two decades. This includes more research on its traditional functions as a passive medium that supports, protects, and encapsulates tissues (14), and its capacity to store elastic energy for explosive activity (15, 16). This also includes exciting new research that implicates fascia as a medium of communication. Levangin, H. hypothesized that this may occur via electrical, cellular, and/or mechanical signals (17). Histological studies have shown this tissue to be densely innervated by free 

 endings, as well as by Pacinian corpuscles and Ruffini endings (17, 18). This inspires consideration of fascia as a sensory organ with a strong link to motion and neuromuscular reflex. Further, Stecco et al. have demonstrated that deep fascia is arranged in layers that may 

 over one another (15). This finding is likely more responsible for inspiring various fascia-specific interventions and is most often referred to when describing fascia’s role in “interpreting” 

Fascia as a Passive Tissue (Traditional Functions):

Fascia as an Active Medium of Communication

 endings, Pacinian corpuscles, and Ruffini endings

May transmit the force of multiple muscles to aid in joint stabilization

Fibroblasts may play a role in increasing 

Image of the fascial system of the body connecting muscles

 invest in the anterior side of the vertebral border of the scapula. Further, although the subscapularis occupies its own fascial compartment, it is covered by a fascial sheath that may be a continuation of the axillary fascia and serratus anterior fascia. This fascia after coursing medially, may invest in the medial border of the scapula, and then fold back over itself covering the subscapularis. Both muscles may contribute to pushing movement patterns that require glenohumeral internal rotation and protraction of the scapula, and both muscles may contribute to approximation of the scapula and rib cage. Further, both muscles are primary stabilizers for the joints they cross during all upper body motions; the subscapularis contributes to compression of the glenohumeral joint, and the serratus anterior contributes to posterior tipping of the scapula. Upper body dysfunction commonly results in these muscles exhibiting opposite alterations in activity (the subscapularis may become over-active, and the serratus anterior may become under-active); however, this is not uncommon for muscles with fascial relationships. Last, further research is needed to determine the fascial relationships between the serratus anterior, subscapularis, and rhomboids. From the currently available publication, it is difficult to determine what continuity exists between the rhomboid fascia and the fascial sheaths discussed above. Tom Myers notes the subscapularis muscle may be part of the Deep Back Arm Line, but admits that the subscapularis does not easily fit into this fascial line as part of a mechanical synergy related to scapular motion (18).

The subscapularis tendon has fascial slips that invest into the anterior capsule, superior and middle glenohumeral ligaments, coracohumeral ligaments, the transverse humeral ligament, and the periosteum of the lesser tubercle just inferior to the supraspinatus tendon which blends with superior shoulder capsule. This may imply that the subscapularis is part of myofascial synergy that contributes to glenohumeral joint stability and arthrokinematic motion. The muscles that invest in the shoulder capsule and may influence capsule tension include the subscapularis, 

, the long head of the biceps brachii, long head of the triceps brachii, and 

 (19). However, considering the structures with direct investment from fascial slips of the subscapularis tendon, the subscapularis may be part of an anterior glenohumeral myofascial synergy with a primary function of resisting anterior glide of the humeral head.

The subscapularis as part of the deep front arm line

Tom Myers, Anatomy Trains: Second Edition. © Elsevier Limited 2009

Electromyographic (EMG) Research: Contribution of the Subscapularis to Exercise and Motion

Comparing Joint Actions (Internal Rotation, External Rotation, Flexion, and Abduction): 

The subscapularis exhibits the most EMG activity during internal rotation (when compared to external rotation, flexion, or abduction), and EMG activity increases with load and abduction/flexion angle. The subscapularis is also one of the few shoulder muscles to exhibit statistically significant EMG activity during all shoulder motions, and the onset of EMG activity is earlier when the motion is expected. Further, there is some evidence to suggest the lower subscapularis exhibits earlier and higher EMG activity than the upper subscapularis during all motions, and the upper subscapularis may be more active during flexion and abduction when compared to internal and external rotation.

 Subscapularis EMG activity increases with load and during concentric contractions. Further, subscapularis EMG activity is likely relatively low during chest press exercises and relatively high during internal rotation; however, subscapularis EMG activity may be highest during compound (multi-joint/multi-planar) exercises that include internal rotation (e.g. close grip row or PNF internal rotation pattern).

Passive and Active Range of Motion (ROM) Exercises:

 During passive and active assisted ROM exercises the subscapularis likely exhibits more EMG activity with increases in length. The most EMG activity is likely exhibited during shoulder flexion, abduction, and or a combination of actions (e.g. putting on and taking off a shoulder sling), and less but significant EMG activity is exhibited during external rotation.

Clinical Tests Performed by Healthy Individuals:

 The subscapularis is likely to exhibit higher EMG activity than other shoulder internal rotators (e.g. pectoralis major, latissimus dorsi, teres major, and anterior deltoid) during the belly-press, bear-hug, lift-off, and internal rotation at 90° of abduction tests. Of those tests, the most subscapularis EMG activity will likely result from the belly-press test, followed by the bear-hug test at 45°, and then the lift-off test during internal rotation at 90° of abduction. Note, that the upper subscapularis may exhibit higher peak EMG activity during the belly-press test, while the lower subscapularis may exhibit higher peak EMG activity during the lift-off test.

Comparing Joint Actions (Internal Rotation, External Rotation, Flexion and Abduction)

Many studies have investigated the electromyographic (EMG) activity of various shoulder and scapular muscles during internal rotation, external rotation, flexion, and abduction. Dark et al. compared 15 healthy males and females (age: 18 - 42 years) with optimal shoulder ROM, normal scapulohumeral rhythm, and no pain or dysfunction in the shoulder during motion. Participants randomly performed shoulder internal and external rotation with the non-dominant shoulder and the elbow flexed to 90°, with 3 different loads (10-20% 1-RM load, 45-55% 1-RM load, 60-70% 1-RM load), for 3 trials/load. Outcome measures included fine wire EMG activity of the subscapularis, pectoralis major, latissimus dorsi, supraspinatus, infraspinatus, and surface EMG activity of the posterior deltoid. The findings demonstrated that the subscapularis, pectoralis major, and latissimus dorsi exhibited a larger increase in EMG activity with increasing loads when compared to the supraspinatus, infraspinatus, and posterior deltoid. The pectoralis major and subscapularis exhibited the highest EMG activity during the internal rotation exercise. The supraspinatus, infraspinatus, and posterior deltoid exhibited the highest EMG activity during the external rotation exercise when compared to the subscapularis, pectoralis major, and latissimus dorsi. The infraspinatus exhibited the highest EMG activity during the external rotation exercise (20). Gaudet et al. compared 25 healthy male and female competitive swimmers (age: 22.6 ± 4.4 years) with no history of shoulder injury or surgery, and no pain during dominant side shoulder internal rotation or external rotation. Participants performed seated internal rotation and seated external rotation with tempos of 60°/sec and 240°/sec, the arm abducted to 30° with the elbow flexed to 90°, for 1 set/variation, 3 reps/set, and short (30 sec) rest between trials. Outcome measures included eccentric and concentric peak EMG activity using fine wire EMG for the supraspinatus, infraspinatus, and subscapularis, and surface EMG for the pectoralis major, latissimus dorsi, upper trapezius, middle trapezius, lower trapezius, posterior deltoid, middle deltoid, and serratus anterior. The findings demonstrated that the infraspinatus, supraspinatus, middle deltoid, posterior deltoid, upper trapezius, middle trapezius, and lower trapezius exhibited higher peak EMG activity during external rotation. The pectoralis major and latissimus dorsi exhibited higher peak EMG activity during internal rotation. Only the pectoralis major and middle trapezius exhibited lower peak EMG activity with an increase in velocity. The subscapularis and serratus anterior were the only muscles that exhibited statistically significant peak EMG activity during internal and external rotation at all testing speeds, with the highest EMG activity exhibited by the subscapularis during concentric internal rotation (21). Heuberer et al. compared 2 females and 9 males (age: 27.6 ± 3.8 years) with no history of shoulder pathology, injury, instability, or impingement, with the ability to achieve full flexion and abduction ROM with their dominant arm during 8 seated shoulder motions. All participants performed abduction from 0° - 180°, flexion from 0° - 180°, and internal rotation and external rotation from 0° to 45° with the shoulder in neutral, 45° of abduction, and 90° of abduction. Outcome measures included fine wire EMG activity of the subscapularis, supraspinatus, infraspinatus, and teres minor and surface EMG activity of the anterior deltoid, middle deltoid, posterior deltoid, pectoralis major, serratus anterior, upper trapezius, middle trapezius, lower trapezius, biceps brachii, and triceps brachii. The findings demonstrated a significant increase in subscapularis fine wire EMG activity during flexion, abduction, and internal rotation, and EMG activity increased with shoulder abduction angle during internal rotation (22). Wickham et al. compared 13 males and 11 females from a university population (age: 23.6 ± 5.3 years) with no history of shoulder pain, injury, or surgery while performing 4 shoulder motions. Participants performed unloaded standing abduction, standing flexion, seated internal rotation, and external rotation with 90° of elbow flexion for 1 set/exercise, 10 reps/set with short (30s) rest between reps. Outcome measures included average fine wire EMG activity of the upper and lower portions of the subscapularis. The findings demonstrated the lower subscapularis exhibited statistically higher average EMG activity during abduction and a trend toward higher average EMG activity during flexion compared to external rotation and internal rotation. The lower subscapularis exhibited earlier average EMG activity during all motions compared to the upper subscapularis (23). Day et al. compared 10 males and 9 females (age: 22.2 ± 1.9 years) with no shoulder pain following shoulder perturbations. Participants randomly responded to unexpected (blindfolded) internal rotation, unexpected external rotation, expected internal rotation, and expected external rotation, 5 trials each, with a short (30-sec) rest between trials. Outcome measures included average "timing of onset" and average EMG activity with fine wire EMG for the subscapularis, infraspinatus, supraspinatus, and surface EMG for the anterior deltoid, and posterior deltoid. The findings demonstrated all muscles tested exhibited earlier average timing of onset during expected rotation when compared to unexpected rotation. The subscapularis exhibited an earlier onset of activity than the other muscles tested during expected external rotation; whereas the infraspinatus exhibited earlier onset timing during the expected internal rotation. The subscapularis and infraspinatus exhibited earlier onset timing during all conditions when compared to the anterior deltoid and posterior deltoid. The subscapularis exhibited higher EMG activity during expected and unexpected external rotation when compared to the infraspinatus and supraspinatus, and the infraspinatus exhibited higher EMG activity than the subscapularis and supraspinatus during expected and unexpected internal rotation. The infraspinatus exhibited greater EMG activity during expected internal rotation when compared to the posterior deltoid; however, the infraspinatus and anterior deltoid EMG activity was similar during unexpected internal rotation (24). These studies suggest that the subscapularis exhibits the most EMG activity during internal rotation (when compared to external rotation, flexion, or abduction), and EMG activity increases with load and abduction/flexion angle. The subscapularis is also one of the few shoulder muscles to exhibit statistically significant EMG activity during all shoulder motions, and the onset of EMG activity is earlier when the motion is expected. Further, there is some evidence to suggest the lower subscapularis exhibits earlier and higher EMG activity than the upper subscapularis during all motions, and the upper subscapularis may be more active during flexion and abduction when compared to internal and external rotation.

Several studies compare the EMG activity of upper extremity muscles, including the subscapularis, during a variety of strength training exercises. Hintermeister et al. compared 19 healthy males (age: 30 ± 6.2 years) with no history of shoulder dysfunction or pain during 7 shoulder rehabilitation exercises with elastic resistance bands. Participants randomly performed internal rotation, external rotation, shoulder shrugs, standing chest press, and 3 variations of seated rows (narrow grip, neutral grip, and wide grip), for 2 sets/exercise, a minimum of 5 reps/exercise, and a moderate rep tempo of 1 rep/2.5 sec. Outcome measures included peak force, average EMG activity, and peak EMG activity via fine wire EMG of the supraspinatus, and surface EMG activity of the subscapularis, infraspinatus, serratus anterior, upper trapezius, pectoralis major, anterior deltoid, and latissimus dorsi. The findings demonstrated the highest peak force occurred during the wide grip row and standing chest press exercises. The supraspinatus exhibited the highest peak EMG activity during the standing chest press and the highest average EMG activity during the wide-grip row. The infraspinatus exhibited the highest average and peak EMG activity during the external rotation exercise. The anterior deltoid and serratus anterior exhibited the highest peak and average EMG activity during the standing chest press. The pectoralis major exhibited the highest peak and average EMG activity during the internal rotation exercise. The subscapularis exhibited the highest average and peak EMG activity during the narrow grip and neutral grip row (e.g. higher than internal rotation) (25). Decker et al. compared 9 healthy males (age: 28.0 ± 5.1 years) and 6 healthy females (age: 25.0 ± 2.4 years) with no history of shoulder injury while performing 7 upper body strengthening exercises (6 with a resistance band). Participants randomly performed a standing chest fly, standing chest press (cued as a bear hug), standing diagonal PNF internal rotation pattern (similar to D2 extension), and standing internal rotation with shoulder abduction at 0° (IR low), 45° (IR mid), and 90° (IR high), as well as bodyweight push-ups with a plus (protraction). Outcome measures included peak force, average and peak fine wire EMG activity of the upper and lower portions of the subscapularis, and average and peak surface EMG activity of the supraspinatus, infraspinatus, latissimus dorsi, and teres major. The findings demonstrated the peak and average EMG activity was highest during the concentric phase of all exercises. The infraspinatus, teres major, pectoralis major, and latissimus dorsi exhibited the highest peak and average EMG activity during the push-ups with a plus. The supraspinatus exhibited higher peak and average EMG activity during the push-ups with a plus, and the lowest peak and average EMG activity during internal rotation at 45° of abduction. The upper and lower portion of the subscapularis exhibited the highest peak and average EMG activity during the push-ups with a plus and standing PNF internal rotation pattern. Both the upper and lower portions of the subscapularis exhibited the lowest EMG activity during the standing chest press (26). Swanik et al. compared 33 healthy physically active males (age: 20.55 ± 2.0 years) with no history of shoulder surgery, instability, or injury for at least 6 months prior to the study while performing 4 different exercises. All participants performed a kneeling ball throw with a 1 kg weight into an inclined trampoline (set at 45 - 60°), a PNF D2 flexion movement pattern with a resistance band, kneeling push-ups with a plus, and kneeling chest flyes with hands on a slide board. The exercises were performed in random order, 10 reps/exercise, 15 sec rest between reps, and long (3-min) rest between each exercise. Outcome measures included fine wire EMG activity and coactivation ratios of the subscapularis, infraspinatus, and teres minor. The subscapularis exhibited significantly higher EMG activity during the kneeling push-up with a plus when compared to the throw and PNF D2 flexion with a resistance band (note, the chest fly resulted in the 2nd most EMG activity). Additionally, similar average coactivation ratios were exhibited by the infraspinatus and teres minor during all 4 exercises; however, the differences in subscapularis EMG activity also resulted in differences in coactivation ratios between the subscapularis and the infraspinatus and teres minor (27). It is challenging to summarize the results of these studies which compare a variety of very different exercises; however, it may be reasonable to conclude that subscapularis EMG activity increases with load and during concentric contractions. Further, subscapularis EMG activity is relatively low during chest press exercises, and relatively high during internal rotation, but EMG activity may be highest during compound (multi-joint/multi-planar) exercises that include internal rotation (e.g. close grip row or PNF internal rotation pattern).

Passive and Active Range of Motion (ROM) Exercises

Additional studies have compared the activity of rotator cuff muscles during exercises commonly performed in a rehabilitation setting. Jung et al. compared 16 healthy males (age: 21 - 30 years), with no history of shoulder pathology or musculoskeletal disorders during 3 variations of passive shoulder flexion, 2 variations of passive external rotation, and 2 variations of active elbow flexion, for 1 set/exercise, 5 reps/set, in random order. Passive shoulder flexion was performed to 170° by sliding a piece of paper across a table with torso flexion, by using a cane, and by using a pulley system. Additionally, participants performed standing passive external rotation using a wall and a cane and standing active elbow flexion with and without a hand supporting the elbow. Outcome measures included peak fine wire EMG activity of the supraspinatus, infraspinatus, and subscapularis. The findings demonstrated that supraspinatus peak EMG activity was higher during passive flexion with a cane or pulley (compared to the table), similar during both variations of external rotation, and higher during elbow flexion without hand support. Infraspinatus peak EMG activity was higher during passive flexion with a cane or pulley (compared to the table), higher during external rotation with a cane (compared to the wall), and similar during both variations of elbow flexion. Peak subscapularis EMG activity was similar during all variations of passive flexion, was lower during external rotation with a cane when compared to the wall, and was similar during both variations of elbow flexion (28). Cross et al. compared 14 healthy males (age: 27.8 ± 3.1 years) and females (age: 24.9 ± 4.5 years) with no history of shoulder injury, surgery, instability, or pain. Participants over the age of 50 were excluded. Participants were instructed to perform 16 exercises (tasks). The 16 exercises included: seated active assisted external rotation with a cane, standing active assisted towel slide on a door into flexion, Codman’s pendulums, active assisted swiss ball rolls on a tabletop into flexion, seated active assisted towel slides on a table into flexion, standing active assisted forward bow into flexion, seated active assisted pulleys into flexion, seated active assisted pulleys into scaption, seated active assisted pulleys into abduction, CPM machine level 1: 30 - 50° abduction and 0 - 10° external rotation, CPM machine level 2: 30 - 95° of abduction and 0 - 25° external rotation, CPM machine level 3: 30 - 140° abduction and 0 - 40° external rotation, putting on the sling with abduction pillow, taking off the sling with abduction pillow, putting on the sling with abduction pillow with assistance, and taking off the sling with abduction pillow with assistance. Outcome measures included average and peak EMG activity using fine wire EMG of the subscapularis, supraspinatus, infraspinatus, teres minor, anterior deltoid, biceps brachii, middle deltoid, middle trapezius, posterior deltoid, and upper trapezius. The findings demonstrated that 12 of the 16 exercises resulted in statistically significant increases in peak EMG activity of the subscapularis. The subscapularis exhibited the greatest peak EMG activity (average peak EMG activity: 35.2% MVIC) during the standing active assisted forward bows into flexion, followed by standing active assisted towel slide on a door into flexion (33% MVIC), standing active assisted forward bows into flexion, standing active assisted towel slides on a door into flexion (33% MVIC), Codman’s pendulums (31.5% MVIC), seated active assisted pulleys into scaption (30.3% MVIC), seated active assisted pulleys into abduction (30.3% MVIC), active assisted swiss ball rolls on a tabletop into flexion (30.1% MVIC), and last the seated active assisted towel slides on a table into flexion (30.0% MVIC) The supraspinatus, infraspinatus, and teres minor exhibited relatively low peak EMG activity during all exercises except for the active assisted Swiss ball rolls on a tabletop into flexion. The anterior deltoid, biceps brachii, middle deltoid, middle trapezius, posterior deltoid, and upper trapezius exhibited relatively low peak EMG activity during all exercises (29). Gurney et al. compared 15 healthy males (age: 33.5 ± 16.4 years) and 13 healthy females (age: 26.5 ± 5 years) with no history of the pathology of the cervical spine, thoracic spine, or shoulder joint, and no pain during range of motion (ROM), rotator cuff exercise, or daily tasks involving the shoulder joint. Participants performed, putting on and taking off a button-up shirt, putting on and taking off a shoulder sling, active assisted ROM using pulleys in the sagittal plane and scapular plane, pendulum exercises (for 10 seconds), self-ranging active assisted ROM in the sagittal plane with hands together and fingers interlocked; self-ranging active assisted ROM using a dowel with index fingers touching each other; passive ROM (flexion) performed by a licensed physical therapist; and walking 10 steps at a self-selected pace with normal arm swing without a sling. Outcome measures included average fine wire EMG activity of the subscapularis, supraspinatus, infraspinatus, and teres minor, and average surface EMG activity of the middle deltoid, upper trapezius, and biceps brachii. The findings demonstrated the teres minor, middle deltoids, and upper trapezius exhibited the most EMG activity during the active assisted ROM using pulleys in the sagittal plane and scapular plane. The infraspinatus and biceps brachii exhibited the most EMG activity while putting on and taking off a sling, and the supraspinatus exhibited the most EMG activity while putting on a shirt, taking off a shirt, and during active assisted ROM in the scapular plane. The findings also demonstrated the supraspinatus, infraspinatus, and teres minor exhibited the least EMG activity while performing the pendulum exercise and passive ROM performed by a licensed physical therapist. The subscapularis exhibited the most EMG activity while putting on and taking off a sling, and the least EMG activity while performing the pendulum exercise and passive ROM performed by a licensed physical therapist (similar to the supraspinatus) (30). In summary, these studies demonstrate that during passive and active assisted ROM exercises the subscapularis likely exhibits more EMG activity with increases in length. The most EMG activity is likely exhibited during shoulder flexion, abduction, and or a combination of actions (e.g. putting on and taking off a shoulder sling), and less but significant EMG activity is exhibited during external rotation.

An interesting group of studies investigated the EMG activity of shoulder muscles during clinical tests performed by healthy individuals. Tokish et al. compared 10 healthy males (average age: 28.4 years) and 6 healthy females (average age: 25.0 years) with no history of shoulder injury. All participants performed the lift-off test and the belly-press test (3-sec isometric hold), in random order, for 3 trials/test. The outcome measures included fine wire EMG activity of the supraspinatus, upper subscapularis, and lower subscapularis and surface EMG activity of the latissimus dorsi, teres major, pectoralis major, and infraspinatus. The findings demonstrated that the upper and lower subscapularis exhibited higher peak EMG activity during the lift-off test and belly-press test when compared to the other muscles tested. The upper subscapularis exhibited higher peak EMG activity during the belly-press test, and the lower subscapularis exhibited higher peak EMG activity during the lift-off test. The other muscles tested exhibited statistically similar activity during both tests (the teres major and supraspinatus exhibited the next highest peak EMG activity); however, all muscles other than the subscapularis exhibited less than 25% maximal voluntary contraction (MVC) (31). Chao et al. compared 21 healthy males (age: 22.95 ± 3.71 years) with no history of shoulder surgery, shoulder injury, or restriction in active or passive ROM during five rotator cuff clinical tests. Participants performed the bear hug with shoulder flexion at 0°, the bear hug with shoulder flexion at 45°, the bear hug with shoulder flexion at 90°, the lift-off test, and the belly-press test, for 4 trials/test. Outcome measures included peak fire wire EMG activity of the upper subscapularis and lower subscapularis and peak surface EMG activity of the pectoralis major and latissimus dorsi. The findings demonstrated that the upper and lower subscapularis exhibited the highest peak EMG activity during the belly-press test and the bear-hug test at 45° when compared to the other tests. Further, the increase in EMG activity was significantly higher for the subscapularis than for the latissimus dorsi and pectoralis major. The lower subscapularis exhibited greater peak EMG activity than the other muscles tested (including the upper subscapularis) during the bear-hug test at 90° (32). Pennock et al. compared 20 males (age: 18 - 45 years) with no history of shoulder, neck, or periscapular pain during 3 variations of the bear hug test, 3 variations of the belly-press test, and the lift-off test. The participants performed the bear hug test with elbow in line with the shoulder, with elbow above the shoulder, and with elbow below the shoulder; the belly-press test with elbow in line with the midline of the body, elbow in front of the midline of the body, and elbow behind the midline of the body, and the lift-off test was performed with conventional protocols. All tests were performed 3 times, with a 3-sec isometric hold/trial. Outcome measures included fine wire EMG activity of the upper subscapularis, lower subscapularis, supraspinatus, and infraspinatus, and surface EMG activity of the pectoralis major, teres major, latissimus dorsi, and the long head of the triceps. The findings demonstrated that the upper and lower subscapularis exhibited statistically similar EMG activity during the bear hug, belly-press test, and lift-off test. The upper and lower subscapularis exhibited higher average EMG activity during all tests when compared to the other muscles tested. The pectoralis major exhibited higher EMG activity during the bear hug test with the elbow below the shoulder, and during the belly-press test with the arm in a neutral position, and in neutral rotation. The latissimus dorsi exhibited higher EMG activity during the bear hug test with the elbow aligned with the shoulder, and during the belly press test with the arm in maximal external rotation. The teres major exhibited higher EMG activity during the belly press test when the arm approached end-range external rotation. Last, the teres major, latissimus dorsi, and triceps brachii exhibited higher EMG activity during the lift-off test when the hand was higher (33). Ginn et al. compared 20 healthy males and females (age: 22.3 ± 2.3 years) with no history of shoulder pain, ROM restriction, and no pain during maximally resisted shoulder internal and external rotation. Participants performed five maximally resisted shoulder internal rotator cuff tests including the belly press test, lift-off test, internal rotation at 0° of abduction in standing, internal rotation at 90° of abduction in standing, and internal rotation at 90° of abduction in supine lying, in random order, 3 trial/test, 3-sec isometric hold/trial, short (30 sec) rest between trials, and moderate (1 min) rest between tests. Outcome measures included fine wire EMG activity of the subscapularis, latissimus dorsi, and teres major and surface EMG activity of the pectoralis major and anterior deltoid. The findings demonstrated subscapularis EMG activity was similar for all tests. The subscapularis exhibited higher activity during the belly press test than the other muscles tested. The subscapularis, latissimus dorsi, and teres major exhibited similar EMG activity during internal rotation at 90° of abduction in supine lying and during the lift-off test (higher than the pectoralis major and anterior deltoid). And, the subscapularis, latissimus dorsi, pectoralis major, and teres major exhibited similar EMG activity during internal rotation at 90° of abduction in standing (higher than the anterior deltoid) (34). In summary, the subscapularis is likely to exhibit higher EMG activity than other shoulder internal rotators (e.g. pectoralis major, latissimus dorsi, teres major, and anterior deltoid) during the belly-press, bear-hug, lift-off, and internal rotation at 90° of abduction tests. Of those tests, the most subscapularis EMG activity will likely result from the belly-press test, followed by the bear-hug test at 45°, and then the lift-off test during internal rotation at 90° of abduction. Note, that the upper subscapularis may exhibit higher peak EMG activity during the belly-press test, while the lower subscapularis may exhibit higher peak EMG activity during the lift-off test.

Electromyographic (EMG) Research: Change in Subscapularis Activity with Dysfunction and Pain

Research comparing the EMG activity of the subscapularis in individuals with and without shoulder pain, suggests that pain results in a complex set of changes that are commonly exhibited by over-active synergists. Perhaps dysfunction results in synergistic dominance of the subscapularis as compensation for pectoralis major and anterior deltoid inhibition. The changes in subscapularis recruitment include a propensity to be shortened by the signs correlated with upper body dysfunction (UBD), lengthened by the arthrokinematic changes correlated with shoulder instability (anterior glide) (12, 38), and a delay in the onset of EMG activity, higher peak EMG activity, and lower average EMG activity when performing functional tasks (38, 39, 42). Most shoulder dysfunction likely results in excessive shoulder internal rotation and a loss of shoulder range of motion (ROM), implying that the subscapularis should be labeled as "over-active and short" and addressed with release and lengthening techniques. However, shoulder instability may imply lengthening and/or under-activity, and subscapularis activation is recommended.

 Over-activity is addressed with release techniques (self-administered or manual), and a decrease in length is addressed with lengthening techniques (self-administered or manual static lengthening). Shoulder instability may be addressed with activation techniques (self-administered).

Dynamic Pec Major, Pec Minor, and Subscapularis Stretch

Movement Impairment and Postural Dysfunction:

: The signs correlated with UBD include "arms fall" and "shoulder girdle elevation" during an 

, and potentially "trunk flexion" during an 

. Further, excessive shoulder internal rotation and scapula anterior tipping (rounded shoulder posture) may be identified during static posture. The subscapularis may contribute to "arms fall" during an 

 by restricting end-range shoulder flexion and abduction, and excessive shoulder internal rotation. Identification of these signs may imply that the subscapularis should be specifically addressed with release and lengthening (stretching) techniques.

Lumbo Pelvic Hip Complex Dysfunction (LPHCD)

: The subscapularis does not play a significant role.

Sacroiliac Joint Dysfunction (SIJD): The subscapularis does not play a significant role.

 The subscapularis does not play a significant role.

Shoulder impingement syndrome (anterior and posterior) (43, 44)

Shoulder instability (anterior capsule laxity) (39, 46, 48)

Subscapularis trigger points (referral pain anterior deltoid) (49, 50)

Shoulder Flexion (with Scapular Motion) <180°

 Subscapularis under-active and long (implies subscapularis activation may be appropriate.)

Top Arm: Inability to reach T7, or the opposite superior angle of the scapula, may indicate subscapularis over-activity.

Bottom Arm: Apprehension in reaching for T7, or the opposite inferior angle of the scapula, may indicate shoulder instability.

Increased stiffness or laxity during anterior-to-posterior or posterior-to-anterior passive accessory motion.

Movement Impairment and the Subscapularis

Common Trigger Point Locations and Referral Pain Patterns for the Subscapularis

This section describes the locations of subscapularis trigger points. Although trigger points may be 

 without knowledge of common locations, learning these locations may improve practice by further increasing reliability and the efficiency of implementing self-administered and manual release techniques. Practitioners will often memorize dozens or 100s of common trigger point locations with relatively little concerted study. This may be accomplished via reading descriptions of trigger point locations, motor point maps, and referral pain patterns like the content below. Followed by practicing the self-administered and/or manual techniques discussed in the next session, and reinforcing that knowledge with repeated use in practice.

The common sites of trigger points in the subscapularis are in the middle of the length of the scapula (between the inferior angle of the scapula and glenoid fossa) and near the glenoid fossa.

Palpation results in tenderness and may result in radiating symptoms, most commonly "deep" in the anterior deltoid region and potentially radiating down the back of the arm, wrist, and hand in a broken pattern (51).

The trigger points and referral pain patterns of the subscapularis muscle

Subscapularis (Self-Administered) Static Release

Subscapularis Static Manual Release

Crucifixion/Cross Stretch (Brookbush Institute preferred method)

Active Pectoralis Major, Pectoralis Minor, and Subscapularis Stretch

Dynamic Pectoralis Major, Pectoralis Minor, and Subscapularis Stretch

Self-administered Shoulder Mobilization

Exercises and Techniques for the Subscapularis

Internal Rotator (Subscapularis) Isolated Activation

Ask your client or patient to hold a monster band in both hands, wrap it around their back, and adjust the band so that when "crossing the arms" the band is kept from sliding toward the head by the distal "ridge" of the deltoids (approximately the level of the deltoid tuberosity).

Ask your client or patient to lie on the side of the subscapularis you intend to activate, with their back against a wall or other solid object.

The patient will anchor the band by maintaining their top arm against their side with their hand (holding the end of the band) on their belly or sternum.

With the elbow of the bottom arm flexed to 90°, ask your patient to adjust their bottom arm to 60 - 90° of flexion, cueing them to "press" (shoulder flexion) into the floor and against the band, which should be wrapped around their arm, just distal to the deltoids. Note, that active shoulder flexion aids in reciprocally inhibiting the latissimus dorsi.

Next, cue the patient to use their bottom arm to press their back and top shoulder into the solid object. Note, this is achieved with shoulder horizontal abduction and will aid in reciprocally inhibiting the pectoralis major.

While maintaining active flexion and horizontal abduction ("arm up" and "pressing into the wall"), ask your client or patient to internally rotate their shoulder ("reaching toward their belly"). Note, the optimal range of motion is about 70°.

Perform 12 – 20 repetitions through the full available range of motion, with a 2:4:2 or 4:2:2 tempo, and move on to your next activation exercise. A second set may be performed if you desire and the patient is capable.

Why is this variation preferred to conventional standing internal rotator strengthening?

The challenge with activating the subscapularis is inhibiting other internal rotators. As the research in the previous section demonstrates, standing internal rotation with the arm in a neutral position is likely to preferentially recruit the pectoralis major, and increasing the shoulder abduction angle is likely to increase latissimus dorsi recruitment. By developing an exercise that is "resisted internal rotation" with flexion and horizontal abduction, it is possible to reciprocally inhibit these prime movers and increase recruitment of the subscapularis.

Subscapularis

Related Courses:

Course Description: Subscapularis

Study Guide: Subscapularis

Webinar: Subscapularis

Etymology of Terms Related to the Subscapularis

Attachement & Innervation: Subscapularis

Where is the Subscapularis Located?

Palpating the Subscapularis

Subscapularis Muscle Actions
1 Sub Section

Fascial Integration

Electromyographic (EMG) Research: Contribution of the Subscapularis to Exercise and Motion
1 Sub Section

Movement Impairment and the Subscapularis

Common Trigger Point Locations and Referral Pain Patterns for the Subscapularis

Exercises and Techniques for the Subscapularis
6 Sub Sections

Shoulder Internal Rotator (Subscapularis) Isolated Activation

Sample Intervention

Bibliography

Related Courses:

Comments

Guest

Subscapularis

Related Courses:

Course Description: Subscapularis

Study Guide: Subscapularis

Webinar: Subscapularis

Etymology of Terms Related to the Subscapularis

Attachement & Innervation: Subscapularis

Where is the Subscapularis Located?

Palpating the Subscapularis

Subscapularis Muscle Actions1 Sub Section

Fascial Integration

Electromyographic (EMG) Research: Contribution of the Subscapularis to Exercise and Motion1 Sub Section

Movement Impairment and the Subscapularis

Common Trigger Point Locations and Referral Pain Patterns for the Subscapularis

Exercises and Techniques for the Subscapularis6 Sub Sections

Shoulder Internal Rotator (Subscapularis) Isolated Activation

Sample Intervention

Bibliography

Related Courses:

Comments

Guest

Subscapularis Muscle Actions
1 Sub Section

Electromyographic (EMG) Research: Contribution of the Subscapularis to Exercise and Motion
1 Sub Section

Exercises and Techniques for the Subscapularis
6 Sub Sections