Retraction Dysfunction

Since this is the first ‘action dysfunction’ we’re going to talk about, there’s some prefacing that needs to take place… In each of these sections on dysfunction, things might start to get a little heavy. It kind of needs to be this way because movement is complex and that means that identifying dysfunctions and understanding what actions we can take to minimize or reduce them, is similarly complex, perhaps even moreso. The intent is not to overload you, but instead to immediately rebuild the pieces of movement we’ve now studied into something that is integrated. Not only because this is really a more accurate picture of how the body is in reality, but also because you’ll be able to help your people better if you have the pieces of the puzzle coming together.

There are going to be even more new terms here, so first, we need to take some time to describe/define them before we use them – this is also going to include some terms we’re already familiar with, but just to make sure we’re crystal clear before moving forward we’ve defined them below.

New terms:

• prime movers – the muscles that contribute the greatest force in the direction of the action in question, and therefore direct the largest contribution to fulfilling a potential range of motion.
• accessory movers – muscles that assist in the direction of the action in question, but aren’t considered to contribute a large amount of force to it. The divide between prime and accessory movers can be quite fine, and some resources will disagree with the classifications we’ve chosen here.
• antagonists – this is not just muscles that are prime movers of the opposite action, but moreso the muscles that oppose the action in question.
• neutralizers/fixators – these two terms are used to describe muscles that limit unwanted movements in a particular action. Many muscles (as you now know) contribute to more than a single action. Neutralizers and fixators will prevent those “extra” movements if that’s desirable for the execution of the skill. The small difference between terms is that fixators are found at the origin of the prime movers, whereas the neutralizers are found at the insertion. We’ve grouped them together because of the functional overlap.
• stabilizers – these are the muscles that whilst they may have a generous contribution to a particular action, they are also primarily suited to joint stabilization through their action. A simplified way to look at it, is that these muscles help to prevent dislocations through a particular action, and enhance control of the action.

Important note:

Remember that as we do this, we’re approaching “dysfunction” with a bit of a broader definition. Because just because something looks different in one person to the next, it doesn’t necessarily mean that something is dysfunctional. Whilst we will be looking at some generalized “universal” markers, again know that these won’t work for absolutely everyone – just a good solid percentage of people. Also, in that same vein, it is a good approach to not only test against these universal markers, but also to test between the two sides of the body within the individual you’re working with.

Lastly, please also remember that “dysfunction” is heavily determined by what “good function” looks like, AND that good function is based entirely upon the activities (both actual and desired) of the person you’re working with. In other words, optimal shoulder girdle function for a cyclist will be VERY different to the optimal function of the shoulder girdle for a gymnast.

Image 1: Scapular retraction with 90 degrees of flexion at the GH joint, standing.

Evaluating Retraction

Optimal ROM:
Unfortunately for us, there’s no agreed-upon method of measuring degrees of motion through retraction of the scapulocostal joint. This means that most references out there won’t even give you a number, and then the few that do have measured angles differently and are therefore not comparable.

Whilst this means that we can’t specifically measure joint angles here, it just means we have to take more of an observational perspective, looking for certain aberrant movement. We’ll discuss things to look out for below.

General Assessment:
Assessment is a little harder without well established norms, and with the reliance on how “good your eye is” in determining imbalances, it makes it something that isn’t going to be the most reliable – yet, if we train our eye, in time it helps us to assess things in a faster way, without necessarily getting out the measuring tools.

With visual assessment we’re largely going to be making a comparison of sides for symmetry of movement. Now, of course, we are asymmetrical and so the presence of an asymmetry is not necessarily a cause of anything – but it’s a good place to start. Especially if one side has pain and the other doesn’t.

Exercise:

• from a regular standing position, ask someone to slowly retract the scapulae (both)
• stand behind them and watch, taking notes to answer the following questions:
–> are both sides moving through “pure” retraction or is there some elevation or depression present on one side?
–> do both move to the same degree? (are they the same distance from the spine at the end of the movement?)
–> are both sides moving at the same rates, or is one noticeably slower or faster than the other?
–> is the inferior angle, the medial border or the superior angle of one side more prominent than the other?
• repeat this slow retraction with arms out in front, at 90 degrees of flexion, and then test again with a weight-bearing position such as a plank, and then test it with a weighted pulling action, like in supine holding onto a bar.

Now we take a look at what the results of this assessment could mean. We’re going to break it down and add more things to think about along the way.

Prime Movers (review):

Rhomboids

Image 2: Rhomboids

It can be difficult to view the action of the rhomboids directly, since they are deep to the trapezius and therefore a clear view of them is blocked. This means that we likely can’t see the contraction of this muscle group.

Instead, when it comes to our visual assessment we’re going to be looking at the larger/grosser features of how scapulocostal retraction is executed. This includes things like the pace of the movement and the absolute degree to which the movement can be executed (how much retraction can this person access?).

Similarly, this includes the strength of the movement – so if we’re wanting to better target an assessment of the prime movers, including the rhomboids, our supine closed-chain retraction is a good test for this. The rhomboids (and trapezius) will need to be strong in order to lift the weight of the torso and allow the scapulae to come together.

Something that I’ve noticed in the clinic as well is that mobility of the thoracic spine is linked to scapulocostal action both in terms of movement capacity and in terms of smooth execution of movement. This has implications for manual therapy below.

Observing a different pace (such as a choppy movement), a different or low degree of absolute retraction, and difficulty performing retraction in the supine closed-chain movement, can be signs that the rhomboids need some work.

Of course, this is not something that’s a guarantee – I will remind you of this as we go along – it’s a guideline to understand what our assessments could mean, and how we can target the prime movers more with our assessment.

Interventions:

If you find that the rhomboids might need some attention, the recipe goes as follows (note, this is my own recipe based on research and experience, not something necessarily agreed upon in the field):

1. Manual therapy – either external application if you’re a trained manual therapist and can offer this to your people, or through the use of some kind of massage tool (there are many effective ones – my personal favourites are RAD rollers – and you can use the code RAD20 to save!). Application should always be slow – when moving too fast you miss things and you don’t give the tissue sufficient time to adapt (both neurally and in terms of the “release” of trigger points). Trigger points of the rhomboids are most commonly found in the region of the rhomboids closest to the medial scapula border (insertion). This doesn’t mean you shouldn’t search around – it’s just a good place to start.
   

   Image 3: Common Rhomboid Trigger Points

   In terms of the thoracic spine mobility, this would likely be something we’d be requesting assistance with from someone clinically trained in adjustments (not necessarily cracking-grade). We do also get a small degree of mobilization of the facet joints by utilizing some RAD rollers close on either side of the spine, and then lifting and lowering the pelvis and/or the head away from the floor slowly. And then incrementally moving along the thoracic region and repeating.

2. Isolated contractions – basically working on scapulocostal retraction in isolation. This is essentially both a post-test to the manual therapy work, to see if it was helpful, and an exercise to use to encourage rhomboid engagement.
3. Integrated movement – both in the immediate sense, with larger, “real” actions (possibly including movements that were noted as being painful, if that’s what you’re working to help), and in the long-term with a gradual approach towards progressive overload, keeping in mind that neural re-patterning is going to take time and repetition.

 
Note: whilst a positive shift in symptoms is certainly a wonderful thing, it doesn’t necessarily mean that you’ve found the source issue. So celebrate a small amount, and then keep in mind that short-term is not our goal, and that we need to view the long-game. This means follow-up with your client is important – do these changes in symptoms LAST? Or do they have a refractory period of a day and then things go back to being the way they were? If they last, that’s another feather-in-the-cap so to speak, AND again it still doesn’t mean we’ve addressed all the things that need to be addressed for truly long-term benefit. So stay on your toes. This goes for ALL the assessments and interventions we’re going through here.

Middle Trapezius

Image 4: Middle Trapezius

Our other prime mover for scapulocostal retraction. It’s more visible thanks to it being superficial (no judgement) 😉 Including the same work as above for assessment of the middle trapezius will also involve looking to see if the muscle itself is contracting. You can also pay attention to the mass of the muscle (especially as retraction continues, the muscles shorten and show us their “bulk”.

Imbalances in the size of the muscles between sides may signal atrophy of the smaller size, which would be a sign of diminished function. Couple that with the other visual cues above (pace and degree of movement) and the strength of movement execution, and we have a solid vision of how the middle trapezius fibers are working.

It should be noted that in the general population, the middle trapezius is commonly long and under-active.

Signs of relative weakness of the mid traps through retraction include (to varying degrees) elevation and anterior tipping of the scapula, as the levator scapulae attempt to help and in essence demonstrate their over-activity. More on this below.

Interventions:

1. Manual Therapy – Trigger points in the middle trapezius are relatively rare, even with consistent under-activity. That being said, if TrPs were to be present they would most likely be located just superior to the spine of the scapula and quite superficially (insertion).
2. Isolated contractions – now, obviously both the rhomboids and the middle traps are noted as being prime movers. This makes it a little challenging to isolate between them, but not impossible. As suggested by data from this study, we are likely to get the greatest relative activity from the middle trapezius (than the rhomboids) if we bring the arm into 90 degrees of abduction, the glenohumeral joint into lateral rotation, and the elbow into terminal extension before then producing horizontal abduction of the arm. This can be easier to isolate when prone, such as the image below.
   

   Image 5: Maximizing middle trapezius engagement whilst minimizing rhomboids engagement.

3. Integrated contractions – even starting with a retraction motion will help to reintegrate middle trapezius activity with rhomboid activity before then taking further steps into additional actions, as noted in the above section with the rhomboids.

Accessory Movers (review):

Latissimus dorsi

Image 6: Latissimus dorsi rendering.

As an accessory mover, the activity of this muscle during scapulocostal retraction is relatively low in comparison to the two muscles above. That doesn’t mean the role of this muscle or any of the following muscles are less important, it just shows us our baseline.

If the latissimus dorsi were to be short and/or over-active (which, by the way, is relatively common), we may tend to see a greater depressive contribution to scapulocostal retraction, in addition to an internal rotation and extension of the glenohumeral joint (we’ll touch more on this when you get into glenohumeral actions).

Interventions:

To help separate things out a little bit, we’ve got this particular section on interventions for the latissimus dorsi over here, where it’s more present as a prime mover. It’s worth noting therefore, that when assessing different actions, when we target our interventions to specific muscles, we’re likely going to see results that spread across multiple actions.

Levator scapulae

Image 7: Levator scapulae muscle.

Levator scapulae is likely going be an oft-spoken name around these parts, considering its common implication in a number of upper limb pain syndromes. In the context of scapulocostal retraction, a shortened and/or overactive lev scap may indeed add in an element of elevation and anterior tipping to the action. Often this may be enhanced by an under-active mid and lower trapezius, which we’ll expand upon soon.

Interventions:

Similarly, we’ve got the details for interventions waiting for you over a scapulocotal elevation, where this muscle is a heavier hitter.

Antagonists:

Serratus anterior

Image 8: Serratus Anterior

We’ll be seeing more of this particular muscle in particular within our discussion on scapulocostal protraction, but we’re going to also see it here for retraction a couple of times, for a couple of different reasons.

Being one of the muscles that works primarily for the opposite action to retraction, if we have a serratus anterior that is either short and/or over-active, we’re going to notice that our range of motion and strength through scpaulocostal retraction is diminished. This may also mean that for example, if you notice a restricted absolute range, it could be related to poor prime mover strength, or chronic over-activity and/or adaptive shortening of the serratus anterior – or BOTH. So don’t just find weak prime movers and stop there with your search.

Interventions:

We cover the interventions for serratus anterior next, in scapulocostal protraction.

Pectoralis minor

Image 9: Pectoralis Minor

In a similar fashion to the serratus anterior, if pectoralis minor is adaptively shortened and/or over-active it can restrict the absolute range of scapulocostal retraction. So once again, keep in mind that finding one piece of the puzzle doesn’t necessarily mean that the puzzle is completed. Keep your attention on the interactions of different structures within the body, because these things are often linked.

Interventions:

We’ll also cover interventions in the next lesson (protraction).

Neutralizers/Fixators:

upper and lower trapezius

Image 10: Delineated regions of the trapezius for ease of visualizing upper and lower regions.

Like I mentioned in the lecture on retraction, whilst the middle trapezius is attributed the primary retractor, the upper and lower traps also play a role in the action in an attempt to neutralize both depression and elevation respectively.

Something that may be surprising to you is that not only are the mid and lower trapezius fibers often adaptively lengthened and/or chronically under-active, but so too is the upper trapezius! Many people believe that they need to lengthen the upper trapezius to get rid of their neck pain, however it’s actually the opposite to what the vast majority of people need (including most athletes). We’ll cover this more, when we talk about scapulocostal elevation.

Considering the frequency of weakness within the trapezius as a whole, mostly we’re needing to focus on strength-based training to improve its function and therefore enhance its ability to appropriately neutralize scapulocostal retraction (among other things of course).

With an under-active and/or lengthened trapezius, this may drive over-activity and adaptive shortening of the levator scapulae, which means that in a good number of instances, the inclusion of ancillary elevation in a retraction movement may infer trapezius weakness and a reduction in its neutralization efforts.

Interventions:

We dig more into interventions for the upper trapezius over here, and the lower trapezius over here, where they are prime movers…or at least where they should be. But to give you something to chew on for the moment, a great activation for both the upper and lower fibers of the trapezius is in the video below:

Intrinsic stabilization subsystem & Anterior Oblique Subsystem

We’re not going to get into this too much here – it’s a future, complicated piece of integration with some of core subsystems.

For now, I’d just like you to know that most of the components of these subsystems are deeply invested in the ways we stabilize ourselves both through movement and when we’re static. They’re also mostly fascially invested with one another and with the “movers” – the muscles we would consider to be more of the generators of action.

These subsystems provide the foundational intrinsic pressure and tension within our system that keep us in integrity.

As it relates to retraction, and all of the actions we’re examining, if an element of these subsystems is dysfunctional we may find that we lose our structural integrity when performing the action in question. On the reverse side of that too, dysfunction in these subsystems can often result in less control of an action, as well as a reduced ability to “uncouple” regions of the body and move things in true isolation. So as we retract our scapulae, are other things moving too? Or are we uncontrolled?

Interventions:

We’re going to keep this relatively short as well, and simply note that the transversus abdominis (you may have heard of this as the TVA) is a part of these subsystems, and a muscle that a good amount of research has been done with (and how it relates to the rest of the muscles within the subsystems).

1. Manual Therapy – For these muscles, manual therapy is less helpful in the majority of instances, so we’ll skip this element here until we dig into it in more detail at a later stage.
2. Isolated contractions – Whilst we can target work towards the TVA, it can’t really be isolated from the subsystem (this is the whole idea of the subsystem). This means that even though we’re talking about isolation, we’re ultimately integrating immediately.
3. Integrated contractions – So here’s an activity that you may be familiar with for strengthening the TVA (and the subsystems of core):

Stabilizers

serratus anterior

We sure are meeting the serratus anterior a lot before even talking about protraction, aren’t we!? Well, that’s because it’s awesome. So in the context of stabilizing scapulocostal retraction, whilst it can restrict the action, it also plays [in the ideal setting] a stabilization role for the medial border of the scapula.

We’d ultimately like the serratus anterior to be keeping the medial border of our scapula close to our ribcage as we retract. And so, when it’s not doing the best job of that we can get “scapular winging” happening, where during retraction we see medial rotation of the scapula, and the protrusion of its medial border. Like this (towards the end you’ll see a retraction movement and note how the therapist is expecting it to wing):

Interventions:

Since the prime movement for the serratus anterior is scapulocostal protraction, we cover interventions over there, keeping in mind that scapular retraction will also be improved by using the work noted (over here) if there is dysfunction.

Image sources:

Image 1: https://www.stack.com/a/the-perfect-plank-for-maximum-shoulder-stability-and-strength
Image 2: https://en.wikipedia.org/wiki/Rhomboid_muscles
Image 3: https://www.nielasher.com/blogs/video-blog/116652869-triggerpoint-therapy-treating-the-rhomboids
Image 4: http://www.mobilityondemand.cards/blog/2015/11/17/how-low-can-you-go
Image 5: http://www.rbf-bjpt.org.br/en-kinesiologic-considerations-for-targeting-activation-articulo-S1413355518310827
Image 6: http://www.musclesused.com/latissimus-dorsi/
Image 7: https://www.kingofthegym.com/levator-scapulae/
Image 8: https://rad.washington.edu/muscle-atlas/serratus-anterior/
Image 9: http://goexercise.eu/muscles/pectoralis-minor/
Image 10: https://www.kingofthegym.com/lower-trapezius/