Shoulder Flexion: Evidence Based Assessment and Treatment

This blog is a synopsis of the excellent review on the topic by Ludewig and Reynolds (2009).


During shoulder flexion the scapula should upwardly rotate and posteriorly and externally rotate at the acromioclavicular joint (Fey et al 2007, van der Helm 1994).

The clavicle elevates and increasingly retracts during shoulder flexion.

For typical alterations in shoulder pathologies see (Ludewig and Reynolds 2009).


Which muscles to strengthen?

The serratus anterior is the only muscle that can produce all three desired scapula motions during shoulder flexion and abduction (Ludewig and Reynolds 2009). Therefore serratus anterior strengthening should be considered in patients with altered scapulo-thoracic kinematics.

Excess clavicular elevation during shoulder flexion indicates potential upper trapezius over activation.

If there is insufficient upward rotation lower trapezius strengthening is indicated.

Which Stretches to use?

Pectoralis minor

The unilateral corner stretch, supine and sitting manual stretches have been compared. The unilateral corner stretch with the arm abducted at 90 degrees and placed against the wall with the patient rotating away from the stretched arm was found to be best for immediate effect (Borstad and Ludewig 2006).

Posterior shoulder capsule

A traditional cross body stretch has been found to be superior to a sleeper stretch, where the scapula is stabilised over 4 weeks for improving passive internal rotation (McClure et al 2007).

Which exercises to use?

Serratus anterior

The push up plus, supine hug, supine punch and wall slide exercises all activate the serratus anterior. The supine hug is often seen as less preferable as it concomitantly activates the pectoralis minor.

If the patient is poor at preventing scapula internal rotation, winging scapula then an exercise like the supine punch may be preferable. In contrast the supine hug exercise places the glenohumeral joint in adduction, internal rotation and flexion.

Lower trapezius

The evidence would support the use of side lying should flexion to 135°, side lying external rotation and prone horizontal shoulder abduction with external rotation to activate the lower trapezius (Cools et al 2007).

Upper trapezius

The push up plus and supine punch activate the serratus anterior but minimally activate the upper trapezius (Ludewig et al 2004).

However, there is conflicting evidence as to whether scapula kinematics can be improved empirically (Kluemper et al 2006, McClure et al 2004, Wang et al 1999).


Borstad, JD.; Ludewig, PM. Comparison of three stretches for the pectoralis minor muscle; J Shoulder Elbow Surg. 2006. p. 324-330.

Cools, AM.; Dewitte, V.; Lanszweert, F., et al. Rehabilitation of scapular muscle balance: which exercises to prescribe?; Am J Sports Med. 2007. p. 1744-1751.

Fey AJ, Dorn CS, Busch BP, Laux LA, Hassett DR, Ludewig PM. Potential torque Capabilities of the trapezius [abstract]. J Orthop Sports Phys Ther 2007;37:A44–A45.

Kluemper M, Uhl TL, Hazelrigg H. Effect of stretching and strengthening shoulder muscles on forward shoulder posture in competitive swimmers. J Sport Rehab 2006;15:58–70.

Ludewig, PM.; Behrens, SA.; Meyer, SM.; Spoden, SM.; Wilson, LA. Three-dimensional clavicular motion during arm elevation: reliability and descriptive data; J Orthop Sports Phys Ther. 2004. p. 140-149.

Ludewig, P.M. and Reynolds, J.F., 2009. The Association of Scapular Kinematics and Glenohumeral Joint Pathologies. Journal of orthopaedic and sports physical therapy, 39 (2), 90-104.

McClure PW, Bialker J, Neff N, Williams G, Karduna A. Shoulder function and 3-dimensional kinematics in people with shoulder impingement syndrome before and after a 6-week exercise program. Phys Ther 2004;84:832–848.

McClure, P.; Balaicuis, J.; Heiland, D.; Broersma, ME.; Thorndike, CK.; Wood, A. A randomized controlled comparison of stretching procedures for posterior shoulder tightness; J Orthop Sports Phys Ther. 2007. p. 108-114.

van der Helm FC. Analysis of the kinematic and dynamic behavior of the shoulder mechanism. J Biomech 1994;27:527–550.

Wang CH, McClure P, Pratt NE, Nobilini R. Stretching and strengthening exercises: their effect on three-dimensional scapular kinematics. Arch Phys Med Rehabil 1999;80:923–929.

evidence based practice, evidence based shoulder assessment, evidence based shoulder treatment, scapulothoracic kinematics, serratus anterior, shoulder assessment, shoulder flexion assessment, shoulder treatment

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