The trapezius muscle is composed of three parts and based on the originating fibers, termed the upper trapezius, middle trapezius and the lower trapezius, respectively.
The lower trapezius fibers are stretched when stretching the mid-back as in child’s pose with arms outstretched, or unilaterally with spinal twist postures as in the ardha matsyendrasana. The middle trapezius fibers are stretched with the interscapular stretch and also with the triceps stretch which is coming up in the next post.
This leaves us with the upper trapezius which is the topic for this post. The upper trapezius muscle originates from the spine of the C7 vertebra, the external occipital protuberance, the medial third of the superior nuchal line (back of the head) and the ligamentum nuchae. The fibers converge laterally and insert onto the posterior border of the lateral third of the clavicle.
Remember as a baby, lying on the stomach and attempting to lift the head up, yes? That was your upper trapezius which enabled you to do that. How about the umpteen shrugs in your lifetime? That is your upper trapezius, also.
This muscle plays a big role in both posture maintenance and movement of the neck and scapulae. Since the head is anterior heavy, the upper trapezius counterbalances the pull of gravity towards cervical flexion. When the bilateral muscles work in synchrony, they extend the neck. Unilaterally activated, it elevates the scapula as in a shoulder shrug or accomplishes same-sided side bends of the neck. Together with the same sided lower trapezius fibers, it rotates the scapula upwards for overhead activities.
Let us look at upper trapezius stretches. As usual, we will consider right sided stretch for consistency and ease of understanding.
As with the levator scapulae, manual techniques work wonders on the upper trapezius muscle. It is possible to release these muscles by yourself as they are easily accessible with your own hands. Static neurological release by holding onto a trigger point and gently increasing the pressure through finger pads for duration of 30 seconds and up to 2 minutes is very effective. Slow circular motion as in kneading also releases these muscles. This should be followed by manual stretching as in side bending and shoulder depression movements to retain the gains made.
Active Static Stretch
i) In early stages, it is best to do stretches in supine as the supported position allows the postural scapular and trunk muscles to relax as well as the upper trapezius to relax maximally as it is not holding the head up countering gravity. To stretch the right upper trapezius, gently depress the right shoulder and hold the position for a full breath cycle. Maintaining this position, slowly tilt the head and neck to the left side and hold for 5 -30 seconds. Repeat 2-3 times.
ii) Seated upper trapezius stretch: It is important to be seated upright with good posture, both feet supported on the floor, weight transfer through the ischial tuberosities with neutral spine and shoulder blades gently pulled back (no squeezing). Next, gently lower the right shoulder down as in depression and tilt head to the left. The cervical side bend to left may be facilitated by gentle pressure using the left hand with palm over the parietal and occipital bones and fingers spread with finger pads below the occipital protuberance. Hold the stretch for 5- 30seconds and release. Repeat 2-3 times.
Active Dynamic Stretch
i) Seated upright with good posture as mentioned above, initiate stretch by pulling shoulder blades back gently and depressing or lowering the both shoulders. Bend the head and neck to the left and hold for 3 seconds, return to the center and bend head and neck to the right for a 3 second hold, all the time maintaining the shoulders in depression. This is a bilateral stretch with alternating side bends. You may do anywhere from 5-10 repetitions.
Unilateral right upper trapezius stretch may also be performed by depressing only the right shoulder and bending head and neck to the left for 3 second hold, bringing head back to neutral and repeat 5-10 times.
Stretching with tools or equipment:
i) Foam Roller: Place the foam roller sideways on the mat or floor. Lie on the foam roller with both the shoulder blades resting on the foam roller with feet on the mat/floor as in hook lying position. Move the body down as the foam roller rolls upwards from the mid-back to the neck region. You may lie down with legs lowered in supine with the foam roller under the curve of the neck and slowly turn the head from side to side, releasing the upper trapezius at the scapular insertion and C7 origin. Roll the foam roller slightly higher and let the occiput rest on the roller. Just hold the position and let the weight of the head release the upper origin of the muscle. Next turn the head from side to side to release the fibers along the occipital protuberance and superior nuchal line.
ii) Tennis ball: This muscle release may be targeted by placing a tennis ball between the wall and the upper shoulder neck area. Slowly roll the ball along the neck to release fibers from the ligamentum nuchae along length of cervical spine.
P.S. Anatomy picture from Wikimedia Commons
File:Cunningham's Text-book of anatomy (1914) (20789827456).jpg
Proceeding further cranially, let’s consider the neck stretches. Today we will look at the levator scapulae.
The levator scapulae is a thin and flat muscle that originates from the transverse processes of the first four cervical vertebrae and inserts into the medial border of scapula from the superior angle to the junction of spine of the scapula.
This muscle functions to rotate the neck and side-bend to the same side and extend the neck. When the cervical spine is stationary, it rotates the scapula downwards with unilateral action, and working bilaterally elevates the scapulae as in a shoulder shrug.
It tightens when there is a forward head posture with a rounded upper back thus resulting in the muscle being used for postural purposes when it is a phasic muscle designed for movement. It is also tightened orat unease when one holds neck in prolonged lateral flexion with rotation- like when holding a phone hands-free between the shoulder and ear.
We will consider the right levator scapulae stretch to keep things straightforward. To stretch the left muscle follow instructions contralaterally.
By far the most effective way to release a tight levator muscle is to have a physical therapist or a trained professional use manual techniques for immediate relief. And then perform a passive stretch to bring the released muscle through the available range of motion.
The levator scapulae is stretched passively in the supine position with the head supported on a mat. This position allows the muscles in the scapula-thoracic area and in the cervical spine to relax. The therapist then sits with chest at level of mat and cradles the occiput within the left cupped hand. This hand then rotates the cervical spine about 45 ° to the left and lifts it up into cervical flexion while the heel of the right hand simultaneously placed at the superior angle of the right scapula, pushes it downwards and away from the cervical spine, thus stretching the muscle fibers through both the insertions. This stretch is held for 15-30 seconds and is essential for the therapist to support the elbows on the mat to hold a sustained stretch, safely, permitting the patient to be at ease.
To stretch this muscle, it takes a small amount of movement at the neck and scapula, however, the starting position with a neutral upright spine is of paramount importance to achieve the stretch accurately.
Active Static Stretch:
i) This is done in an upright seated posture on the chair or edge of mat with the feet firmly supported on the ground. The knees are hip width apart with thighs parallel. The ischial tuberosities are weight bearing with the pelvis in neutral position and a natural lumbar lordosis. The shoulders are directly over the hip joints while the spine is maintained in elongated position with the scapulae gently pulled back. This automatically puts the cervical spine in good starting position. The head is turned to the left about 45 ° or with the chin pointing to left knee. Next bend the neck forward and slightly to the side (as in bringing the ear closer to the left shoulder). The right arm is extended behind the trunk and the scapula is depressed or lowered to experience the stretch. Hold this position for 5-30 seconds and release. Repeat 2-3 times.
ii) A slight variation to the above stretch is when the right arm is elevated overhead and then flexed at elbow with the hand reaching the medial border of the right scapula. This rotates the glenoid fossa of the scapula upwards and in the process the superior angle moves down, pulling the scapular insertion of the levator away from its origin in the cervical spine, thus stretching it.
Both the above techniques cause the reciprocal inhibition of the levator scapulae by engaging the lower trapezius (scapular depressor) and the upper trapezius and serratus anterior (scapular upward rotators), respectively. Holding the stretch for a prolonged period also causes autogenic inhibition of stretched muscle fibers.
(P.S.- the 2 pictures of seated levator stretch and its variation show left levator stretch)
Active Dynamic Stretch:
i) This may be done at a wall in the standing position, feet hip width apart and few inches from the wall. Stand with the back along the wall and the scapula retracted to make maximal contact with the wall. The scapulae are then depressed bilaterally and this position is held for 1-2 breath cycles. Next turn the head 45° to the left and look down with a slight side bend and forward flexion to left so that gaze is directed to left big toe. Bring the left hand behind the head with fingers on the occiput and hold the head position firmly. Without elevating the right scapula (no shoulder shrug), raise the right arm overhead and into shoulder elevation. Hold end position for 2-3 seconds as you breathe in and exhale as you lower the arm beside the trunk. Repeat 4-5 times for 1 set. Do 2-3 sets.
Stretch with Equipment and Tools:
i) A foam roll placed on floor perpendicular to the spinal column at the level of the shoulder blade or scapula does wonders to stretch the upper back muscles. Slowly move the foam roll upwards while lying on it, face up. When the foam roll is just a few inches below the neck, rest the back on the floor with the legs bent at hip and knees, feet on floor (hook lying position). Hold the foam roll at the upper scapular border and let the body weight sink you into the roll. Move the roll up further along the spine till the base of cervical spine and hold for few seconds. Turn the neck side to side when the roll fits into the lordosis of the spine to release the muscle insertion on the transverse processes of the vertebrae.
ii) The foam roll may be arranged vertically along the spine and rolled side to side to release the muscles along the medial border of scapula.
iii) Tennis ball progression is also very effective and gives more precise release by rolling the ball in the vicinity of the levator scapulae insertion at superior angle of scapula while lying face up on the tennis ball on a mat on the floor or even standing with the ball between a wall and the upper back.
This week we will look at inter-scapular stretch.
The word inter-scapular literally means the area between the two scapulae or the shoulder blades. The scapula is a bone that sits on the posterior wall of the rib cage and is held in place by its soft tissue attachments. The scapula-thoracic joint is not a regular synovial joint, hence there is no bone to bone approximation with either the vertebrae or ribs which is enclosed by a joint capsule, and is unique from that perspective. It varies in its placement over the ribs. Normally it lies between the T1-T7 vertebrae with the base of scapular spine at T3 level and the inferior angle at T7 spinous process. It also varies in its placement medio- laterally and usually the distance between the medial borders of the scapulae to the vertebral spinous process at T3 level is 6-10 cm. The left and right scapula in the same individual may be situated differently over the rib cage, given the fact that it does not form a synovial joint and is only held in place by muscular attachments.
As a physical therapist, what is important during examination is whether the left and right scapula are situated similarly within the same individual. Studies in multiple subjects only helps determine a range of “normal “or “acceptable” placement and would alert of gross dyskinesis leading to symptomatic conditions. History in these cases is important as is the overall postural alignment. Fine tuning the scapulae and balancing them bilaterally by releasing the tight muscles and developing smooth and coordinated motor control at scapula-thoracic, shoulder, and acromio-clavicular joints leads to stable movement.
That being said, we will look at inter-scapular stretch in healthy individuals who are asymptomatic to maintain normal scapular alignment. There are several muscle attachments to the medial border of the scapula, namely, the levator scapulae, rhomboid minor and major, and the serratus anterior. The trapezius muscles originate from the spinal vertebrae, the occiput, and ligamentum nuchae and the various fibers insert into the clavicle, the spine of scapula, and acromion process. In addition, the superficial postural muscles or erector spinae (iliocostalis, spinalis, longissimus) and deep postural muscles (semispinalis, multifidi) also traverse this area. Clinically, a skilled therapist may be able to locate the trigger points or tight muscle/ tendons through palpation. Since the presentation and symptoms may vary widely, what is of significance though is a healthy range of motion in the scapula and shoulder joint which is balanced and bilaterally symmetrical.
For these stretches our presumption is tightness in the muscles between the shoulder blades with a shorter distance from the spine to medial border of scapula. In this case, the shoulders are drawn back and scapula may appear squeezed or closer together. Generally speaking, when the shoulders are rounded, the pectorals are tight and should be addressed with chest and shoulder opening stretches. When asymmetrical, do the stretches on the tighter side. When one side is tighter than the other, first priority will be to balance both sides by stretching and working on the tighter tissue, then follow up with bilateral stretches when balanced.
Passive Stretching Techniques
Passive techniques will encompass manual release by therapist which is very effective for these muscles. Myofascial release techniques to relieve trigger points and increase flexibility in soft tissue. Passive stretches may be done manually also, since this is a small and freely moving bone which may be manually protracted to get a stretch in the inter-scapular muscles.
i) Unilateral stretch in the inter-scapular area may be achieved by lifting the arm up at the shoulder and drawing it across the chest to the other side. The wrist should be slightly lower than the shoulder joint. It is important to keep the shoulder blade neutral (not elevated) when beginning this stretch. This stretch may stretch the posterior shoulder capsule as well. Emphasis should be placed to feel the stretch between shoulder blades by continuing to stretch a little further so the scapula is pulled across the back to the side being stretched. . Hold stretch for 5-30 seconds. Release and repeat 2-3 times.
ii) Another way to stretch the inter-scapular area is in quadruped position with wrists directly below the shoulders and knees below the hips. A good starting position makes the stretch easier by targeting accurate soft tissue. Slowly bring chin to chest while lifting and rounding the upper and mid-back. The scapulae move outwards along the ribs, stretching the inter-scapular area. Hold stretch for 5-30 seconds. Release and repeat 2-3 times.
iii) An additional stretch involves facing a sturdy open doorway while standing with feet hip width apart a few inches from the doorway. With the shoulders internally rotated and forearms pronated hold onto door way on both sides with a hook grip so that the thumb is pointing to the floor. Lean back using body weight as you round the shoulders and upper and mid-back area as if you are hanging on the hands. Hold stretch for 5-30 seconds. Release and repeat 2-3 times.
Stretch with equipment or tools:
i) Foam Roller and Tennis Ball Stretch: The best tool to stretch the interscapular area initially is a foam roller. Place the foam roller on the floor and lie on it facing upwards so that the roller targets the area between the shoulder blades. Make sure the transverse abdominus is engaged for a neutral lumbar spine. Roll the foam roller sideways to stretch. As you progress, you may try a tennis ball between the shoulder blades on the floor or in standing position with the ball in the inter-scapular area between the wall and your shoulder blades. Apply pressure gradually to tolerance and roll the ball by small circular motion or just hold in place for 5-30 seconds, when ball is directly over tight spot.
(P.S. The 2 anatomical pictures are modified from Wikimedia Commons.)
One of the large muscles that fans over the chest is the pectoralis major. The other muscles in the pectoral region are the pectoralis minor, serratus anterior, and subclavius. The pectoralis minor lies under the pectoralis major.
The pectoralis major originates from the sternum, 1st -6th costal cartilages, the aponeurosis of the external oblique muscle, the medial half of the anterior surface of the clavicle. It inserts into the bicipital groove of the humerus.
The pectoralis minor originates from the 3rd to 5th ribs and inserts into the coracoid process of the scapula.
Whereas the pectoralis major moves the shoulder into adduction and turns the arm inwards, the pectoralis minor facilitates movement by pulling the scapula anterio-inferiorly into the thoracic wall. Both these muscles are tonic muscles and are prone to tightness and shortening.
While the anterior torso stretches are applicable to stretch the pectorals, let us go through some specific and targeted stretches for the pectorals.
This is done in the seated position with the therapist encircling the shoulders from the back and gently elevating and retracting the shoulder blades. This opens the chest and the stretch position is held for 5-30 seconds and released with a 15-30 second rest between stretches.
Active Static Stretch:
i) This is done while standing and facing the corner in a room. Place both hands, palms facing on each of the two walls at shoulder height. Assume a stride position with the front foot about a foot away from the corner, and engage the transverse abdominus to stabilize the spine in neutral position. The leg forming the back stride leg is kept straight at the knee. Push the palms into the wall engaging the serratus anterior. Slowly move forward over the front ankle joint to lean the trunk into the corner while the chest area opens up and shoulder blades are squeezed together. Hold stretch for 5-30 seconds and release, with 15-30 second rest in between stretches.
Active Dynamic Stretch:
i) This may be done in the standing position or seated on a stool without a back rest. Assume a good seated posture with feet flat on the floor and a neutral, upright spine. Extend both arms at shoulders behind the back, and interlace the fingers behind the base of spine and slowly raise the hands up and away from the back, while squeezing the shoulder blades and opening the chest/shoulder region. Hold the stretch for 5-30 seconds and release, with a 15-30 second rest in between stretches.
ii) Dhanurasana or the bow pose:
This is done in prone position, lying on the stomach with arms by the side of trunk, palms facing upwards. Bend both the knees bringing the heels of feet to ischial tuberosities or sit bones and hold the feet around the ankles with your hands. As you inhale, lift the heels away from the ischial tuberosities and lift the thigh off the floor as the torso lifts up. Squeeze the shoulder blades by rotating the shoulder out and pulling them back, hence opening the chest/shoulder region. Ensure both knees are no more than hip width apart. Hold for 2-3 breath cycles and release by first lowering the thighs and torso while bending the knees. Lastly release the hand-hold around the ankles and extend knees.
Stretching the pectorals with tools and equipment
i) Foam Roll Stretch:
This may be done on the bare floor or on exercise mat on the floor. Place the foam roll (at least 36 inches or longer) lengthwise along the mat. The spine is supported on the foam roll with the face up and feet on the floor as in hook-lying position. The occipital protruberance (back of head) and the spine to the sacrum should be supported on the roll while the Transverse Abdominus is engaged for neutral spine. It is important to not arch the back and maintain the gentle anatomical curves. Bending the arms at the elbows, bring the dorsum of hands onto the mat on either side of the torso. Rotate shoulders outwards and supinate the forearms with 90° of elbow flexion, and slowly slide the dorsum of hands in an upward arc towards the head maintaining the contact of the hands with the floor at all times. This opens the chest and shoulder region, stretching the pectoral muscles. Hold for as long as possible between 5-30 seconds as far up as you reach with the hands and slide the arms back to release the stretch. Rest for 15-30 seconds in between stretches.
While most core training programs emphasize on strengthening the abdominal muscles, not enough importance is given to stretching and maintenance of mobility or flexibility. A good program for healthy population will involve both stretching to maintain flexibility and mobility as well as contraction of muscles and soft tissue to maintain stability and strength. This gives a wider range of movement to work with at the same time providing a stable spine and trunk on which these movements will be based.
This brings to forefront the issue of what exercise program to follow: traditional yoga, traditional Pilates, or contemporary exercise regimes (walking, running, bicycling, and swimming, engaging in sports)? Well, worry not, choose what you may, physical therapy is here to the rescue. Imagine your work out to be a multi layered complex movement pattern. Physical therapists can peel these down to the basic movement patterns involved (view from the ground-up or inside-out) in any activity. If the base pattern is flawed, the movements imposed on the base patterns will follow suit. Consider a building standing on a foundational block which is stable and sturdy- the building structure it supports will be strong and stable as well. Since physical therapy considers movement patterns and biomechanics, it is a precise science which may be used to reproduce the movement patterns and eventually automatize the healthy movement patterns till it becomes habit.
Having said that, let’s get back to the anterior torso stretch; we will look at all the structures that are involved when the trunk is stretched namely:
i) the muscles and tendons like the iliopsoas in hip and lumbar spine region, abdominals (rectus abdominis and obliques in lower to mid trunk), the pectorals and serratus anterior in the chest together with the intercostal muscles, deltoid in the shoulder region, and the sternocleidomastoid and deep neck flexors in the cervical spine/neck region
ii) ligaments, like the anterior longitudinal ligament (ALL) which runs along the front of the vertebral bodies
iii) fascia, like the aponeurosis of the insertion of transversus abdominus and obliques, linea alba
iv) dermal tissue (skin).
Various soft tissues have varying elastic properties and stretches must be performed gently and over prolonged periods to achieve flexibility. The anterior torso is stretched through backward bends. These stretches are active stretches and have been considered in various other posts. I will group them here for a clear understanding of anterior torso stretch.
Active Dynamic Stretches for Anterior Torso
There are several yoga asanas that stretch the hip flexors and the anterior torso. These asanas are intermediate to advanced level as they entail nuances in muscle control, and to be done correctly, should be done in presence of trained instructor and practiced solo after learning them initially. Since they involve back extension which narrows the foraminal space, they are contra-indicated in certain conditions like back ache and neck pain and digestive disorders.
i) The Anjaneya asana: You basically start in half-kneeling position with the left foot on the floor in front and the right leg resting on the knee and ball of foot, behind. Slide the right knee back as far as possible and lunge forward on the left foot by shifting the body weight forward and arching the lumbar spine forward into lordosis with arms outstretched overhead to keep spine elongated. This stretches the front of the right hip, thigh, and anterior spine to effectively stretch the psoas and iliacus, the rectus abdominus and the ALL. Hold pose for 2-3 breath cycles and release by first engaging abdominals to bring spine to neutral and then shifting body weight to come out of lunge position.
ii) Dhanurasana or the bow pose: This is done in prone position, lying on the stomach with arms by the side of trunk, palms facing upwards. Bend both the knees bringing the heels of feet to ischial tuberosities or sit bones and hold the feet around the ankles with your hands. As you inhale, lift the heels away from the ischial tuberosities and lift the thigh off the floor as the torso lifts up. Ensure both knees are no more than hip width apart. Hold for 2-3 breath cycles and release by first lowering the thighs and torso while bending the knees. Lastly release the hand-hold around the ankles and extend knees.
iii) Ustrasana or camel pose: Begin in kneeling position on the mat with knees hip width apart and dorsum of foot resting on the floor. Place both the hands around the waist, thumb in front and fingers around the back. Gently tilt pelvis back by engaging the abdominals and elongate the lumbar spine. Inhale and lift the sternum (breast bone) upwards. Bring the knee and elbow joints closer together by internally rotating hips and externally rotating shoulders. Stay here for 2-3 breath cycles and slowly slide hands down the back, by extending elbow joints, to the heels of feet. Open the shoulders without squeezing the shoulder blades (releasing the pectorals) and extend the neck by eccentric contraction of neck flexors for slow controlled movement.
iv) Bhujangasana: This is one of the postures in the Suryanamaskar. It is done from the prone lying position on the mat (facing the floor) with the dorsum of feet resting on the floor. . The legs are resting on the floor from shin to thigh as you begin lifting the torso while extending the lumbar spine and push the chest out as spinal extension continues along the thoracic spine. The spine should simultaneously stay elongated as you achieve a uniform curve, moving up towards mid and upper back. Lastly extend the neck looking upwards and back. The palms facing down, resting on the floor are just behind the shoulders in the beginning and end up in front of shoulders as end posture is reached. The elbows may be in any degree of flexion to complete trunk extension, based on available range of spinal extension and trunk lift from the floor. Finally, you can push the palms into the mat as you open up the chest by rolling shoulder blades down and in (pectoral and deltoid stretch).
v) Backward bend or Hasta Uttanasana: This is the second and eleventh posture in the Suryanamaskar. You begin in standing position (tadasana) with feet about hip width apart. Raise hands upwards overhead with the elbows extended, palms open and stretched out, and upper arms in line with ears as you arch the spine backwards in a backward bend. As you begin the movement, the legs start moving forward at the ankle joints as a unit from lower legs to the hips with the hip joints in extension, the pelvis rotates anterior and the spine from the sacrum to the cervical region starts a gradual and uniform extension movement, the shoulders are neutral with shoulder blades rotated upwards as the gaze fixes upwards on hands or ceiling.
Ami Gandhi is a licensed physical therapist in the state of California. She is the owner of StableMovement Physical Therapy, a small boutique practice in San Jose that offers patient centered, one-on-one, hands-on physical therapy.