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Blackburn Exercises

Original Editor - Shreya Pavaskar

Top Contributors - Farah Elzanaty, Vidya Acharya, Lucinda hampton, Shreya Pavaskar, Alexandra Stead and Céline Gueissaz  

Introduction

Blackburn exercises are a set of six prone therapeutic positions designed to strengthen the rotator cuff and scapular stabilising muscles.[1] They were developed from a now-classic 1990 electromyographic (EMG) study, in which fine-wire intramuscular electrodes were used in 28 subjects to identify which joint positions best activated the supraspinatus, infraspinatus and teres minor.[1] Later EMG studies have since confirmed and extended these findings, including to deeper scapular stabilisers. [2] [3] [4][5][6] The exercises are most often used clinically in people with scapular dyskinesia and related shoulder conditions.[7][8]

Relevant Anatomy

Posterior view of the scapula
Lateral view of the serratus anterior muscle
Three portions of the Trapezius

The scapula is a thin, flat triangular bone situated on the postero-lateral aspect of the thoracic cage, serving as the osseous attachment for 17 muscles and functioning as the dynamic link between the thorax and upper limb.[7] Together with its supporting joints and muscles, it acts as a stable, dynamic base that allows smooth and efficient shoulder movement.[8] The primary scapular stabilisers are the serratus anterior and the three portions of the trapezius (upper, middle, and lower), whose coordinated action, known as force coupling, is essential for normal scapulohumeral rhythm during arm elevation.[8] The rotator cuff muscles (supraspinatus, infraspinatus, teres minor, and subscapularis) work synergistically with the scapular stabilisers to keep the humeral head centred in the glenoid.[2] This coordination allows efficient force transfer during upper limb tasks.[4][2]

Clinical Background

Scapular dyskinesia refers to any visible alteration in scapular position or movement relative to the thoracic cage, at rest or during arm movement.[7] It is not a primary diagnosis, but a physical impairment.[7] It can contribute to, or result from, subacromial pain syndrome (SAPS), rotator cuff tendinopathy, glenohumeral instability and labral pathology.

The SICK Scapula Syndrome is a related clinical presentation characterised by:

  1. Scapular malposition
  2. Inferior medial border prominence
  3. Coracoid pain and malposition
  4. DysKinesis of scapular movement[9][10]

Blackburn exercises are commonly used in SICK scapula rehabilitation, because they strengthen the scapular muscles that are typically inactive in this presentation.[1] The underlying neuromuscular mechanism typically involves disrupted force coupling between the upper, middle, and lower trapezius and the serratus anterior, resulting in reduced scapular upward rotation, posterior tilt, and external rotation during arm elevation.[8] [11] In athletes with rotator cuff tendinopathy, the lower trapezius and serratus anterior activate later relative to the upper trapezius, alongside reduced scapular upward rotation early in arm elevation, which reinforces the force-coupling explanation.[12] Blackburn exercises directly address these impairments by loading the posterior rotator cuff and scapular stabilisers, while minimising upper trapezius substitution.[8][11] People with subacromial impingement show significantly greater pectoralis minor activity during arm elevation than healthy controls, suggesting that deeper stabilisers beyond the trapezius and serratus anterior also play a role in scapular dyskinesia. [13] A 2024 trial of 90 participants found scapular stabilisation tailored to the type of dyskinesis produced greater improvement in Constant-Murley scores than a conventional exercise programme, sustained at six-week follow-up.[14] The Constant-Murley score is a validated composite measure of shoulder pain, function, range of motion and strength.[15] It is also worth noting that the common visual Scapular Dyskinesis Test, has shown poor diagnostic accuracy against objective EMG measurement in asymptomatic individuals, therefore a visual assessment alone should not be over-interpreted.[16]

Indications for Prescribing Blackburn exercises

Blackburn exercises are typically indicated for the conditions below:

Thoracic hyperkyphosis has also been associated with increased shoulder pain and disrupted scapulohumeral rhythm, so clinicians may extend Blackburn exercises to this population. This link is correlational, rather than a direct trial of Blackburn exercises in patients with thoracic hyperkyphosis.[19]

A 2025 review of 14 trials (n=666) with shoulder impingement syndrome found that adding scapular stabilisation to general exercise improved pain, function and abduction range of motion.[20] Widening the lens beyond scapular-specific exercise, a 2026 systematic review of 20 trials (n=1,152) with rotator cuff related shoulder pain found that exercise therapy generally, not scapular-specific programmes, produced significant pain reduction and gains in function and range of motion.[21] This reinforces exercise as a sound first-line approach while showing that scapular-specific programmes such as Blackburn exercises are one reasonable option rather than a uniquely superior approach.[21]

Blackburn Exercise Fundamentals

All six Blackburn exercise positions share the same set-up. The patient lies prone with the forehead resting on the plinth, which allows the cervical spine and neck musculature to relax.[1] The upper trapezius must stay relaxed throughout the movement.[8] Visible or palpable shrugging of the shoulders constitutes a technique error and must be corrected before loading is progressed.[8] Scapular retraction is actively held throughout each movement.[8] Movements are performed in a slow, controlled manner with a brief isometric hold at end range before lowering.[1] Exercises begin with bodyweight resistance only.[1] Small hand-held weights maybe added once technique is consistent, with load individualised to the persons tolerance and goals.[8]

[22]

Blackburn Exercise Breakdown

Each of the six Blackburn exercises, features a unique arm position designed to target specific combinations of rotator cuff and scapular muscles.

Prone "I" — Prone Extension

  • Position: Prone, arms extended alongside the body with palms facing upwards (forearms supinated).[1]
  • Movement: With scapulae retracted, lift both arms simultaneously off the plinth, keeping them parallel to the thorax. Hold briefly, then lower with control. [1]
  • Primary muscles targeted: Lower trapezius, posterior deltoid.[1]

Prone "Y" — Prone Abduction at 110° (Thumb Up)

  • Position: Prone, shoulders abducted to approximately 110° relative to the thorax, thumbs pointing upwards, arms positioned approximately 30° anterior to the coronal plane (in the scapular plane).[1]
  • Movement: With scapulae retracted, lift both arms off the plinth simultaneously. Hold briefly, then lower with control.[1]
  • Primary muscles targeted: Infraspinatus. Positioning the shoulder at approximately 110° of abduction with external rotation preferentially loads the infraspinatus, as demonstrated by EMG analysis.[2][3]

Prone "Y" — Prone Abduction at 110° (Thumb Down)

  • Position: The same position is used, with the forearms pronated so that thumbs point towards the floor.[1]
  • Movement: Retract the scapulae and lift both arms off the plinth simultaneously. Hold briefly, then lower with control.[1]
  • Primary muscles targeted: Rhomboids.[1]

Prone "T" — Prone Horizontal Abduction at 90° (Thumb Up)

  • Position: Prone, elbows extended, shoulders abducted to 90° with full external rotation so that thumbs point towards the ceiling.[1]
  • Movement: Retract the scapulae and lift both arms off the plinth simultaneously. Hold briefly, then lower with control.[1]
  • Primary muscles targeted: Supraspinatus and middle trapezius. Prone horizontal abduction with the humerus in external rotation has consistently demonstrated high supraspinatus EMG activity.[3][4]

Prone "T" — Prone Horizontal Abduction at 90° (Thumb Down)

  • Position: Same position, with the forearms pronated so that the thumbs point towards the floor.[1]
  • Movement: Retract the scapulae and lift both arms off the plinth simultaneously. Hold briefly, then lower with control.[1]
  • Primary muscles targeted: Rhomboids and middle trapezius.[1]

Prone Horizontal External Rotation

  • Position: Prone, shoulders abducted to 90° with elbows flexed to 90°, forearms hanging vertically towards the floor.[1]
  • Movement: Externally rotate the glenohumeral joint so that the forearms rotate upwards until parallel with the plinth. Maintain scapular retraction throughout. Hold briefly at end range, then lower with control.[1]
  • Primary muscles targeted: Infraspinatus and teres minor. Prone external rotation at 90° of glenohumeral abduction with the elbow at 90° has been shown to maximise infraspinatus and teres minor activity.[4]

Progression of Blackburn exercises

Exercises should begin with bodyweight only and progress to light hand-held weights once correct technique, meaning, sustained scapular retraction with no upper trapezius substitution, can be maintained for three sets of 15 repetitions.[8]

Elastic resistance, such as resistance bands, is a reasonable next step because it provides accommodating resistance through range.[8] Progression from prone to standing positions using elastic resistance is appropriate once prone control is well established.[18] Standing diagonal patterns and serratus-anterior-focused exercises, such as the wall push-up plus, fit at this stage once good prone scapular control is demonstrated.[18] For overhead athletes specifically, progression towards sport-specific loading should follow demonstration of reliable scapular control in the lower load prone positions.[14]

Precautions for prescribing Blackburn exercises

Blackburn exercises, like other loaded rotator cuff and scapular exercises, should be introduced cautiously in the presence of an acute or full-thickness rotator cuff tear pending surgical assessment.[23] They should also be delayed after recent shoulder surgery until medical or surgical clearance has been given to load the repair.[23] An acute inflammatory flare affecting the shoulder is a further reason to defer loaded exercise until it settles.[23] Uncontrolled pain that prevents a person from maintaining correct scapular retraction and a neutral cervical position is also a reason to modify or postpone the exercise.[23] As with any resistance-based rehabilitation, technique should be established with bodyweight before load is added, and increasing or sharp pain during the exercise should prompt reassessment.[23]

Summary

Blackburn exercises are built on classic EMG work identifying optimal joint angles for loading the rotator cuff and scapular stabilisers.[1] They are commonly used in conditions such as scapular dyskinesia, SICK scapula syndrome, subacromial pain, and rotator cuff tendinopathy.[7] [8] [9][11] Applying the exercise correctly, by maintaining a relaxed upper trapezius and sustained scapular retraction is crucial, especially in early rehabilitation.[1][8]

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 Blackburn TA, McLeod WD, White B, Wofford L. EMG analysis of posterior rotator cuff exercises. J Athl Train. 1990;25:40–45.
  2. ↑ 2.0 2.1 2.2 2.3 Otis JC, Jiang CC, Wickiewicz TL, Peterson MG, Warren RF, Santner TJ. Changes in the moment arms of the rotator cuff and deltoid muscles with abduction and rotation. J Bone Joint Surg Am. 1994 May;76(5):667-76. PMID: 8175814.
  3. ↑ 3.0 3.1 3.2 Malanga GA, Jenp YN, Growney ES, An KN. EMG analysis of shoulder positioning in testing and strengthening the supraspinatus. Med Sci Sports Exerc. 1996 Jun;28(6):661-4.PMID: 8784752.
  4. ↑ 4.0 4.1 4.2 4.3 Reinold MM, Wilk KE, Fleisig GS, Zheng N, Barrentine SW, Chmielewski T, Cody RC, Jameson GG, Andrews JR. Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises. J Orthop Sports Phys Ther. 2004 Jul;34(7):385-94.PMID: 15296366.
  5. ↑ Berckmans KR, Castelein B, Borms D, Parlevliet T, Cools A. Rehabilitation Exercises for Dysfunction of the Scapula: Exploration of Muscle Activity Using Fine-Wire EMG. Am J Sports Med. 2021 Aug;49(10):2729-2736. Epub 2021 Jul 19. PMID: 34279126.
  6. ↑ Sasaki S, Kenmoku T, Otera A, Miyajima G, Nagura N, Nakawaki M, Nakazawa T, Takaso M, Fukuda M, Takahira N. Electromyographic analysis of infraspinatus and scapular muscles during external shoulder rotation with different weight loads and positions. J Orthop Sci. 2019 Jan;24(1):75-80. Epub 2018 Sep 6. PMID: 30197094.
  7. ↑ 7.0 7.1 7.2 7.3 7.4 7.5 Panagiotopoulos AC, Crowther IM. Scapular Dyskinesia, the forgotten culprit of shoulder pain and how to rehabilitate. SICOT J. 2019;5:29. Epub 2019 Aug 20. PMID: 31430250; PMCID: PMC6701878.
  8. ↑ 8.00 8.01 8.02 8.03 8.04 8.05 8.06 8.07 8.08 8.09 8.10 8.11 8.12 8.13 Cools AM, Dewitte V, Lanszweert F, Notebaert D, Roets A, Soetens B, Cagnie B, Witvrouw EE. Rehabilitation of scapular muscle balance: which exercises to prescribe? Am J Sports Med. 2007 Oct;35(10):1744-51.Epub 2007 Jul 2. PMID: 17606671.
  9. ↑ 9.0 9.1 9.2 Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology Part III: The SICK scapula, scapular dyskinesis, the kinetic chain, and rehabilitation. Arthroscopy. 2003 Jul-Aug;19(6):641-61. PMID: 12861203.
  10. ↑ Murena L, Canton G, Vulcano E, Cherubino P. Scapular dyskinesis and SICK scapula syndrome following surgical treatment of type III acute acromioclavicular dislocations. Knee Surg Sports Traumatol Arthrosc. 2013 May;21(5):1146-50. doi: 10.1007/s00167-012-1959-9. Epub 2012 Mar 30. PMID: 22461014.
  11. ↑ 11.0 11.1 11.2 11.3 Zhong Z, Zang W, Tang Z, Pan Q, Yang Z, Chen B. Effect of scapular stabilization exercises on subacromial pain (impingement) syndrome: a systematic review and meta-analysis of randomized controlled trials. Front Neurol. 2024 Mar 1;15:1357763. PMID: 38497039; PMCID: PMC10940535.
  12. ↑ Leong HT, Ng GY, Chan SC, Fu SN. Rotator cuff tendinopathy alters the muscle activity onset and kinematics of scapula. J Electromyogr Kinesiol. 2017 Aug;35:40-46. doi: 10.1016/j.jelekin.2017.05.009. Epub 2017 May 30. PMID: 28595162.
  13. ↑ Castelein B, Cagnie B, Parlevliet T, Cools A. Scapulothoracic muscle activity during elevation exercises measured with surface and fine wire EMG: A comparative study between patients with subacromial impingement syndrome and healthy controls. Man Ther. 2016 Jun;23:33-9. Epub 2016 Mar 22. PMID: 27183834.
  14. ↑ 14.0 14.1 Tang L, Chen K, Huang L, Liang J, Wang M, He L, Liu L, Li L, Ma Y. Efficacy of Targeted Scapular Stabilization Exercise Versus Conventional Exercise for Patients With Shoulder Pain: A Randomized Clinical Trial. Am J Phys Med Rehabil. 2024 Sep 1;103(9):771-776. Epub 2024 Feb 20. PMID: 38376127.
  15. ↑ Vrotsou K, Ávila M, Machón M, Mateo-Abad M, Pardo Y, Garin O, Zaror C, González N, Escobar A, Cuéllar R. Constant-Murley Score: systematic review and standardized evaluation in different shoulder pathologies. Qual Life Res. 2018 Sep;27(9):2217-2226. Epub 2018 May 10. PMID: 29748823; PMCID: PMC6132990.
  16. ↑ Ramiscal LS, Bolgla LA, Cook CE, Magel JS, Parada SA, Chong R. Is the YES/NO classification accurate in screening scapular dyskinesis in asymptomatic individuals? - A novel validation study utilizing surface electromyography as a surrogate measure in identifying movement asymmetries. J Man Manip Ther. 2025 Apr;33(2):122-132. Epub 2024 Dec 5. PMID: 39635986; PMCID: PMC11924258.
  17. ↑ Kibler WB, Uhl TL, Maddux JW, Brooks PV, Zeller B, McMullen J. Qualitative clinical evaluation of scapular dysfunction: a reliability study. J Shoulder Elbow Surg. 2002 Nov-Dec;11(6):550-6. PMID: 12469078.
  18. ↑ 18.0 18.1 18.2 Kibler WB, Sciascia AD, Uhl TL, Tambay N, Cunningham T. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. Am J Sports Med. 2008 Sep;36(9):1789-98. doi: 10.1177/0363546508316281. Epub 2008 May 9. PMID: 18469224.
  19. ↑ Yarayan Y, Şevgin Ö. Association of thoracic kyphosis angle with shoulder pain, range of motion, isokinetic muscle strength, and upper extremity function. BMC Musculoskelet Disord. 2026 Feb 20;27(1):255. PMID: 41721347; PMCID: PMC13032620.
  20. ↑ Brasileiro A, Sousa C, Schindler I, Tanaca B, Oliveira M, Martins R, Arcanjo F, Neto MG. Scapular stabilization exercise on pain and functional recovery in people with shoulder impingement syndrome: a systematic review and meta-analysis. Phys Sportsmed. 2025 Jun;53(3):189-196. Epub 2025 Mar 7. PMID: 39983700.
  21. ↑ 21.0 21.1 Vico-Rodríguez, P., Aibar-Almazán, A., Hita-Contreras, F. et al. Exercise interventions for rotator cuff-related shoulder pain in middle-aged and older adults: a systematic review and meta-analysis. BMC Musculoskelet Disord 27, 692 (2026).
  22. ↑ PT Jon. Blackburns- Blackburns for Shoulder Strengthening. Available from: https://www.youtube.com/watch?v=Q6xDe4p1jVM
  23. ↑ 23.0 23.1 23.2 23.3 23.4 Thigpen CA, Shaffer MA, Gaunt BW, Leggin BG, Williams GR, Wilcox RB 3rd. The American Society of Shoulder and Elbow Therapists' consensus statement on rehabilitation following arthroscopic rotator cuff repair. J Shoulder Elbow Surg. 2016 Apr;25(4):521-35. PMID: 26995456.
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