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Dry Needling for Scapular Winging

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This week’s article is a guest post from Michael Infantino.  Michael reached out to me on Facebook and sent me the below videos of a patient’s improvement in scapular winging after dry needling the serratus anterior.

I wanted to share the below article that Michael wrote showing the videos, but also talk about how trigger points may be involved.

I’m not sure what to make of these videos, if trigger points are involved, or exactly how dry needling the serratus anterior helped this patient’s winging.  But I am sure that I was impressed with the results.  I wish we knew more about the reasoning and mechanism, but in the meantime I’m happy we can help people feel and move better.

Dry Needling for Scapular Winging

Can we correct scapular winging in a matter of minutes?  This obviously depends on the cause of the scapular winging.

It is well documented that injury to the long thoracic nerve or cervical spine may lead to medial border scapular winging or dyskinesia of the scapula (Meininger, 2011). These are always challenging.  Ruling out neuromuscular cause can be done with a nerve conduction velocity test or EMG.  

But a recent patient of mine, made me think…

Research has continually shown that muscles with trigger points demonstrate the following:

  • Altered muscle activation patterns on EMG (Lucas, 2010; Wadsworth, 1997)
  • Reduced muscle strength (Celik, 2011)
  • Accelerated muscle fatigue (Ge, 2012)
  • Reduced antagonist muscle inhibition (Ibarra, 2011)  
  • Increased number of trigger points on the painful side (Alburquerque-Sendin, 2013; Bron, 2011; Fernandez-de-las-Penas, 2012; Ge, 2006; Ge, 2008)

Appreciating these findings would lead most to conclude that treatment of trigger points could improve scapular mobility and timing. This was my immediate thought when I noticed a significant medial border scapular winging while watching my patient raise and lower his arm.

It wasn’t until I read this research that I began using dry needling to do more than just manage pain. The results seen following dry needling to the serratus anterior were remarkable.

After seeing this amount of scapular winging, I dry needled his serratus anterior muscle.  Note the remarkable improvement:

How Trigger Point Dry Needling May Impact Scapular Winging

It is well documented that appropriate muscle activation patterns (MAP) surrounding the shoulder is necessary for efficient and pain free mobility (Lucas, 2003). Lucas and group actually gauged the effect of trigger point dry needling on MAP in subjects with latent trigger points (LTrP).

“Latent myofascial trigger points (LTrPs) are pain free neuromuscular lesions that are associated with muscle overload and decreased contractile efficiency” (Simons et al., 1999, p. 12). MAP’s of the upper trapezius, serratus anterior, lower trapezius, infraspinatous and middle deltoid were compared in a group with LTrP’s and one without. Following surface EMG, the LTrP’s were treated with trigger point dry needling. Surface EMG was performed after treatment as well.

Findings from this study were as follows:

  • Muscle activation of the upper trapezius in the LTrP group pre-treatment.
  • Early activation of the infraspinatous in the LTrP group pre-treatment.
  • Increased variability of muscle activation in all muscles assessed in the LTrP group pre-treatment compared to the control group.  
  • Altered MAP of distal musculature (infraspinatous and middle deltoid) were consistent with co-contraction, a finding that has been attributed to increased muscle fatigability (Chabran et al., 2002).
  • Improved muscle activation times in the LTrP group following dry needling.
  • Significant decrease in the variability of muscle activation in the LTrP group following dry needling, except for the serratus anterior.
  • The serratus anterior and lower trapezius showed increased variability in both the control and LTrP group, which may be why the results did not reach significance. This is also consistent with the latest research in JOSPT that found dyskinesia to be normal in asymptomatic populations. (Plummer, 2017).

Based on the both my clinical experiences and the research presented in this paper, it would seem highly valuable to focus on the treatment of trigger points to restore muscle activation patterns surrounding the shoulder complex.

Being able to press the “reset button” on a muscle is important for re-establishing normal muscle activation patterns prior to exercise. Inclusion of other manual therapy and exercise techniques is important for optimizing function of the local musculature (range of motion, hypertrophy, strength and endurance).

No research that I am familiar with has compared dry needling to other manual therapy techniques for restoring MAP in muscles adjacent to the shoulder. Future research that compares various trigger point treatments for restoration of normal MAP would be beneficial.

 

About the Author

Dr. Michael Infantino, DPT, is a physical therapist who works with active military members in the DMV region. You can find more articles by Michael at RehabRenegade.com.

References

  • Alburquerque-Sendin, F., Camargo, P.R., Vieira, A., Salvini, T.F., 2013. Bilateral myofascial trigger points and pressure pain thresholds in the shoulder muscles in patients with unilateral shoulder impingement syndrome: a blinded, controlled study. Clin. J. Pain 29 (6), 478e486.
  • Bron, C., de Gast, A., Dommerholt, J., Stegenga, B., Wensing, M., Oostendorp, R.A., 2011a. Treatment of myofascial trigger points in patients with chronic shoulder pain: a randomized, controlled trial. BMC Med. 9, 8.
  • Chabran, E., Maton, B., Fourment, A., 2002. Effects of postural muscle fatigue on the relation between segmental posture and movement. Journal of Electromyography and Kinesiology 12, 67–79.
  • Celik, D., Yeldan, I., 2011. The relationship between latent trigger point and muscle strength in healthy subjects: a double-blind study. J. Back Musculoskelet. Rehabil. 24 (4), 251e256.
  • Cummings, T.M., White, A.R., 2001. Needling therapies in the management if myofascial trigger point pain: a systematic review. Archives of Physical and Medicine and Rehabilitation 82, 986–992.
  • Ge, H.Y., Arendt-Nielsen, L., Madeleine, P., 2012. Accelerated muscle fatigability of latent myofascial trigger points in humans. Pain Med. 13 (7), 957e964.
  • Ge, H.Y., Fernandez-de-las-Penas, C., Arendt-Nielsen, L., 2006. Sympathetic facilitation of hyperalgesia evoked from myofas- cial tender and trigger points in patients with unilateral shoul- der pain. Clin. Neurophysiol. 117 (7), 1545e1550.
  • Ge, H.Y., Fernandez-de-Las-Penas, C., Madeleine, P., Arendt- Nielsen, L., 2008. Topographical mapping and mechanical pain sensitivity of myofascial trigger points in the infraspinatus muscle. Eur. J. Pain 12 (7), 859e865.
  • Hillary A. Plummer, Jonathan C. Sum, Federico Pozzi, Rini Varghese, Lori A. Michener. Observational Scapular Dyskinesis: Known-Groups Validity in Patients With and Without Shoulder Pain. J Orthop Sports Phys Ther:1-25.  
  • Ibarra, J.M., Ge, H.Y., Wang, C., Martinez Vizcaino, V., Graven- Nielsen, T., Arendt-Nielsen, L., 2011. Latent myofascial trigger points are associated with an increased antagonistic muscle activity during agonist muscle contraction. J. Pain 12 (12), 1282e1288.
  • Lucas KR, Polus BI, Rich PS. Latent myofascial trigger points: their effects on muscle activation and movement efficiency. J Bodyw Mov Ther. 2004;8:160-166Lucas KR, Polus BI, Rich PS. Latent myofascial trigger points: their effects on muscle activation and movement efficiency. J Bodyw Mov Ther. 2004;8:160-166
  • Lucas KR, Polus BI, Rich PS. Latent myofascial trigger points: their effects on muscle activation and movement efficiency. J Bodyw Mov Ther. 2004;8:160-166Meininger, A.K., Figuerres, B.F., & Goldberg, B.A. (2011). Scapular winging: an update. The journal of The American Academy of Orthopaedic Surgeons, 19(8), 453-462.
  • Simons, D.G., Travell, J.G., Simons, L.S., 1999. The Trigger Point Manual, Vol 1, 2nd Edition. Williams and Wilkins, Baltimore, USA.
  • Wadsworth, D.J.S., Bullock-Saxton, J.E., 1997. Recruitment patterns of the scapular rotator muscles in freestyle swimmers with subacromial impingement. International Journal Sports Medicine 18, 618–624.

 

Yoga Stability Push Up

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yoga stability push upI’ve recently been playing around with a variation of the yoga push up on an unstable surface.  The yoga push up exercise integrates a push up with a plus with the downward dog yoga position.  You can also perform this exercise on an unstable surface, such as a stability ball.

How to Perform the Yoga Stability Push Up

Here are a few of my coaching cues during the yoga stability push up:

  • Place the stability ball up against a wall.  The instability provided the ball is plenty, having the ball mobile isn’t needed and may not be safe.  Also, don’t perform this on turf as it is sometimes hard to keep the feet from slipping.
  • Start at the beginning plank position at the top of the push up.  In this position prep you body by finding neutral spine and performing a mild abdominal brace.  Keeping the core stable with enhance the mobility benefits at both the shoulders and hips.
  • Perform a push up but on the push back up focus on your hands pushing up and out above your head to drive your hips up high.  Protract your shoulders to perform a “push up with a plus.”  Be sure to keep your core stable and hinge at your hips.  You should feel both your abdominal area and glutes engage.

 

Benefits of the Yoga Stability Push Up

There are many benefits of incorporating the yoga stability push up into your routine.  The three big things I am looking to improve with this exercise are:

  • Shoulder and scapular stability.  Performing a push up on an unstable surface has been shown to enhance scapular muscle activity compared to a traditional push up.  This can also be said for the rotator cuff muscles.
  • Serratus anterior activity.  The push up with a plus includes both upward rotation and protraction of the scapula, the two motions of the serratus anterior that when performing together have been shown to enhance serratus activity.
  • Hip mobility.  By adding the downward dog yoga hip hinge portion of the exercise, you drive more elevation of the arms, but also help facilitate a hip hinge pattern.

Using Unstable Surfaces to Enhance Scapular Stability

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A common goal of many rehab, fitness, and sports performance programs is to enhance scapular stability.  The scapula provides a base of support for the shoulder during functional movements.  Any deficits in the scapula’s ability to move and stabilize can result in scapular dyskinesis, winging, and poor positioning of the shoulder joint, which has been shown to correlate to shoulder injuries.  This is particularly important in athletics that involve the overhead shoulder position, such as throwing.

SEE ALSO: How to Assess and Treat Scapular Dyskinesis

Programs are often designed to work on strength and dynamic stability of the scapular stabilizers.  These tend to focus on the muscles like the trapezius and serratus, which work together to provide protraction and upward rotation of the scapula.

One specific exercise that is commonly performed is the push up with a plus exercise.  This has been shown to produce high levels of EMG activity of the serratus anterior.

A recent study from the Journal of Physical Therapy Science evaluated the EMG activity of the scapular muscles during the push up with a plus exercises with the following variations:

  • Performing a full push up with a plus in the standard position on the toes in comparison to on the knees
  • Performing the push up with a plus on a stable in comparison to an unstable surface

The study produced two important findings that essentially confirmed many common beliefs, but are worth discussing.

 

Push Ups Performed From the Knee Position Decreases  Muscle Activity

Push up with a plus on kneesThis finding makes senses as the body weight load and lever arm are reduced when performing the push up on your knees instead of in the standard toe position.  This study confirms this finding, showing that push ups with a plus can be regressed to on the knees or progressed to on the toes based on the specific needs of each person.  There is a subsequent change in muscle activity as the position becomes more challenging.

 

Push Ups Performed on an Unstable Surface Produce Greater Scapular Muscle Activity

scapular stability push up on unstable surfaceAnother finding confirmed that an unstable surface does produce greater amounts of scapular activity.  Exercises performed on unstable surfaces were quite popular in the past but have decreased in popularity as many people have suggested that this may not actually be a very functional activity.  I think this study confirms that performing a push up on an unstable surface can be an effective exercise to enhance scapular control and stability.

No, if you are trying to gain pec strength or chest hypertrophy you would not perform a push up on an exercise ball.  That is true.  But if you are trying to enhance scapular control during a functional closed chain activity, such as pushing, I think using an unstable surface is beneficial.

This is really no different than a bottom up kettlebell exercise or using the landmine for a press.  I’ve described the serratus slide exercise that I developed using the TRX suspension system in the past as well, just as another example.

All of these activities require you to stabilize forces in multiple planes of motion while perform a single plan movement.  This is the essence of what Eric Cressey and I talk about in our Functional Stability Training series (with an Upper Body module coming soon!).

 

If you are trying to enhance someone’s scapular stability and possible reduce scapular dyskinesis, performing the push up with a plus exercise on an unstable surface appears to be a valuable option.

 

Using Science to Enhance Exercise

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Inner Circle Premium Content

The latest webinar recording for Inner Circle members is now available below.

Integrated Science and Evidence to Enhance Exercises

I use the serratus anterior as a model for discussion but the information is easily applicable to any muscle.  The below webinar will help you understand:

  • What we often miss when performing simple and traditional exercises only
  • How to critically assess how and why we do exercises
  • What to consider when selecting and enhancing exercises
  • How to take your exercise programming to the next level
  • How to make faster gains and better outcomes
  • Why you need to integrate baseline strength and functional stability training

To access the webinar, please be sure you are logged in and are a member of the Inner Circle program.

TRX Serratus Slide

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serratus anteriorThe serratus anterior is an extremely important muscle that helps control normal shoulder and scapular function by protracting and upwardly rotating the scapula. In addition, the serratus assists in stabilizing the scapula against the rib cage, preventing scapular winging. These are all critical functions of the serratus that help prevent shoulder impingement.

Because the serratus is so important in functional arm movements, exercises to strengthen and enhance neuromuscular control of the serratus should be incorporate into many training and rehabilitation programs, especially in those with shoulder dysfunction.

While traditional protraction exercises have been effective in strengthening the serratus, recent research has identified that serratus activity is increased when combining both protraction and upward rotation of the scapula (Ekstrom et al JOSPT 2003). This movement helps train the serratus in a functional pattern that combines the muscle’s several important roles in scapular mobility.

Based on this research, I began using a dynamic jab exercise as baseline exercises for basic training and rehabilitation of the serratus (Reinold et al JOSPT 2009).  I discussed this and other techniques in training the serratus in my webinar that you receive free for signing up for my newsletter, so check that out if you haven’t already.

However, this exercise is quickly mastered and further challenge is often required. Incorporating a closed kinetic chain position and unstable surface training will require a greater degree of dynamic stability of the scapula and promote neuromuscular control. Thus, I began incorporating the TRX Suspension Trainer to further advance the exercise.

The TRX Serratus Slide

The TRX Suspension Trainer is an excellent method of performing the Serratus Slide movement that challenges both the strength and stabilizing functions of the serratus muscle. Furthermore, the amount of challenge can quickly be adjusted by modifying the angle of the exercise.

TRX Suspension Trainer Serratus Slide

I really have found a bunch of great uses for the TRX Suspension Trainer, and this is just one example.  I am going to keep sharing some of the exercises that I incorporate the TRX straps.

Also, I just recently got my hands on the new TRX Rip Trainer, this thing is pretty cool, I have started to use this a lot in my programs, specifically for some of the exercises in my Functional Stability Training system, they work great for enhancing core stability.