From Slump to Strength: Rethinking the Upper Back

We hear about “core strengthening” for the low back and legs all the time, but what stabilizes the upper body?

Traditionally, the “core” refers to the abdominal muscles, obliques, low back paraspinals, and gluteal muscles (as you already know from my low back pain article). While most wouldn’t necessarily think of the upper back as part of the core, I would argue that the upper back musculature is critical in maintaining upper body functionality and stabilizing yourself during movement; it also plays a huge role in injury prevention and longevity, especially given our modern-day lifestyle.

For context, some of the most common upper extremity injuries I see include:

• Neck pain: usually muscular and caused by tight cervical paraspinals (muscles in the back of the neck) and the trapezius muscles (muscle connecting your neck to your shoulder), leading to neck stiffness and limitations in motion.

• Myofascial pain syndrome: often starts as neck pain from tight muscles or “knots” (trigger points) and can progress to radiating pain down the arm. Since muscles are all linked by fascia (a web of connective tissue), when one area gets tight, it pulls on neighboring muscles like a series of rubber bands tugging on each other, leading to widespread discomfort and stiffness.

• Shoulder pain: usually a tendonitis (inflammation around the tendon connecting bone to muscle - read more on my inflammation article) of the rotator cuff tendons that’s painful with certain motions and exercises, especially overhead exercises.

• Elbow pain: tennis or golfer’s elbow, which refers to a tendonitis that hurts with gripping, lifting, or moving the wrist or elbow.

• Wrist pain: frequently caused by tendonitis, leading to pain with gripping, hand use, or moving the wrist.

• Pinched nerve in the neck: Caused by pressure on a nerve from a bulging disc or arthritis-related narrowing of the spaces in the spine which cause severe nerve pain down the arm (see my chronic pain article for more).

What do these injuries have in common?

1. Overuse or repetitive strain — This may be from playing one sport too much, overdoing the same exercise, or even long hours of computer work.

2. Poor posture — In today’s world, we perform far too much scapular pronation – rounding of the shoulders with slumped over posture. Our sedentary lifestyles, computer work, texting, and amount of time we spent sitting contribute to this. We have to combat this with scapular retraction — think puffing out your chest by using your upper back muscles- more on this later.

3. Weak upper back — Without a strong foundation from the larger upper back muscles (which are built to handle greater forces) your body moves less efficiently. This can overload smaller muscles, tendons, and joints, increasing the risk of overuse injuries.

4. Poor neuromuscular control — Neuromuscular control refers to how your brain and muscles work together to coordinate movement and maintain stability. Having strength is one thing, but you have to be able to use those muscles in the right way at the right time. If you’re strong at doing weighted rows but those muscles stay inactive during your everyday movements, that strength isn’t translating into real-world function and not being put to good use.

Scapular stabilization is one of the most important and overlooked aspects of neck and upper extremity health. Improving scapular stability supports better posture, enhances upper back strength, and sharpens neuromuscular control. It is crucial not only for preventing rotator cuff injuries, neck pain, and elbow or wrist tendonitis, but also for optimizing performance in everyday tasks and exercise.

So, what is scapular stabilization?

Your scapula (shoulder blade) is a large bone with several muscles connecting to it that guide shoulder movement.

The shoulder relies heavily on the scapular stabilizer muscles to maintain proper positioning throughout movement. When these muscles are weak or imbalanced, it can lead to abnormal shoulder blade motion, which decreases shoulder function and increases the risk of injury.

Scapular stability depends on the coordinated activity of the surrounding musculature. These are important muscles and include mainly your upper back musculature (levator scapulae, rhomboids, serratus anterior, and trapezii).

These muscles work together to dynamically position the scapula, providing a stable base for efficient shoulder movement. Factors affecting scapular stability include posture, muscle imbalances, overuse, trauma, and abnormal shoulder motion. Proper scapular stabilization enhances shoulder strength by up to 24% and is critical for maintaining optimal shoulder range of motion.

Targeted Scapular Stabilization Exercises

1. Resistance Band Rows: Use a resistance band to perform rowing motions, focusing on squeezing your shoulder blades together.

2. Straight arm lat pulldown:

   1. Anchor a resistance band at chest height.

   2. Hold the band with both hands, arms extended in front of you.

   3. Pull the band straight back, keeping your arms parallel to the ground.

   4. Squeeze your shoulder blades together at the end of the movement.

   5. Slowly return to the starting position.

3. Reverse Fly:

   1. Sit with knees bent, holding a light dumbbell in each hand.

   2. Lean forward, letting your arms hang down next to your calves.

   3. Slowly raise the weights until your elbows are level with your shoulders.

   4. Focus on squeezing your shoulder blades together.

   5. Lower the weights back to the starting position with control.

For these exercises, it is more important to maintain proper form throughout the movement, avoiding any swinging or using momentum. These exercises target the posterior deltoids, rhomboids, and trapezius muscles, enhancing scapular stability. For more tips on how to get started or what repetition/set scheme to follow, read my resistance training article.

Other Exercises to Consider:

4. Scapula Pushups: In a plank position, perform a pushing motion with your arms, allowing your shoulder blades to protract and retract.

   

5. Supermans: Lie prone (i.e., face down) on the floor with your arms extended straight overhead (or by your sides for a modified version). Gently lift your chest, arms, and legs off the ground while drawing your shoulder blades down and back. Hold for 10–30 seconds, focusing on activating the muscles of your upper back and glutes without overarching your low back.

   

6. I-Y-T-W Formation: Perform these exercises lying prone, lifting your arms in various formations to form these letters in order to strengthen different scapular muscles

7. Wall Slides: Stand with your back against a wall, lifting and lowering your arms to the side while maintaining contact with the wall.

Posture and Biomechanics

Proper posture is fundamental to scapular stability and overall shoulder health. Poor posture, such as rounded shoulders or a forward head position, can alter scapular position and contribute to shoulder tendonitis and other upper extremity issues. Maintaining good posture with the shoulders back and down helps position the scapula optimally, allowing for efficient shoulder movement.

Correct biomechanics during daily activities and exercise is equally important. This includes maintaining scapular control while elevating your arm. By focusing on posture and biomechanics, you complement the effects of targeted exercises, creating a comprehensive approach to upper back and shoulder health.

Real World Example

By the time patients see me, they’ve usually already tried and failed physical therapy for “strengthening.” Many people mistakenly think that if the wrist is painful and weak, the wrist itself needs to be strengthened (e.g., gripping exercises) or that if the elbow is injured, the elbow needs to be strengthened (e.g., bicep curls or tricep extensions).

However, this can often make the problem worse since this body part is already overused and this methodology contributes to further overuse and/or damage to the tendons.

Let’s use the example of a tennis player with elbow pain while playing. He is already gripping a lot while playing, so doing more isolated gripping exercises with physical therapy will likely just make the problem worse. Instead, by focusing on rows, pull-ups, and the exercises above (which still do involve grip strength), overtime the kinetic chain (how different parts of your body work together to produce movement) will be much stronger and more efficient, ultimately offloading the injured elbow and solving the problem.

Common Pitfalls

1. Over-activating the trapezius muscle (by shrugging the shoulders) — This is the number one issue I see that prevents progress. These muscles already tend to be tight in most of us, so while doing these exercises the scapulas should try to be pulled back/together rather than up. This comes back to neuromuscular control - activating the right muscles during the motion.

2. Concern about symmetry — I get pushback from patients who want a well rounded program without overemphasis on any one body part, including the upper back. My response is that these foundational muscle groups need to be prioritized more than smaller or less functional groups (e.g., arms). Remember that the chest and the back work in opposition, so those with significant scapular pronation should 1) work their back more than their chest, or 2) work on opening up the chest with mobility exercises while strengthening the upper back. I’m not trying to take away anyone’s chest or arm day (who doesn’t love a good chest pump!), but we need to be tailoring our training based on our individual muscular imbalances rather than rigidly following a “symmetric” routine.

3. Pain while doing the exercises — If this is the case, this either means that the exercises aren’t being done in proper form (perhaps over-activating the trapezius or going too heavy) or that your muscles are so tight or filled with trigger points/knots that they are not activating properly. In this case, they need to be loosened up prior to beginning the strengthening with other tools, such as massage/myofascial release, trigger point injections, cupping, or other hands-on treatments.

The TLDR

Incorporating scapular stabilization (i.e., upper back) exercises into your fitness routine, along with maintaining proper posture and biomechanics, can significantly reduce the risk of injury and keep you more functional. Whether you're an athlete, a weekend warrior, or someone who sits at a desk all day, understanding how to strengthen and more importantly, activate the muscles around your shoulder blades is essential for optimal musculoskeletal health and performance.

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About the Author: Rohit Jayakar MD specializes in non-surgical Sports Medicine (Physical Medicine & Rehabilitation). He treats a variety of musculoskeletal injuries, neurological injuries, and pain conditions.

Sources and Recommended Readings:

Moezy A, Sepehrifar S, Solaymani Dodaran M. The effects of scapular stabilization based exercise therapy on pain, posture, flexibility and shoulder mobility in patients with shoulder impingement syndrome: a controlled randomized clinical trial. 2014 Aug 27;28:87. PMID: 25664288; PMCID: PMC4301231.

Paine R, Voight ML. The role of the scapula. Int J Sports Phys Ther. 2013 Oct;8(5):617-29. PMID: 24175141; PMCID: PMC3811730.

Scapular Dyskinesia, the forgotten culprit of shoulder pain and how to rehabilitate, Andreas Christos Panagiotopoulos and Ian Martyn Crowther, SICOT-J, 5 (2019) 29, DOI: https://doi.org/10.1051/sicotj/2019029

Image Credits: Shoulder Exercises; Scapular Posture