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Integrated functional anatomy of the serratus anterior. Attachments, nerves, palpation, joint actions, arthrokinematics, fascia, triggerpoints, and behavior in postural dysfunction. Examples of common activation exercises, subsystems, and strength exercises for the serratus anterior.

Serratus Anterior

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I have almost completed my CPT certification and am half-way through the Human Movement certification to inform my massage practice. The different modalities of reading, watching audiovisual materials, and attending live or recorded webinars have been important to my learning style and for review.

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I have been following Brent Brookbush for nearly a decade- back when I was a personal Trainer and now as a Physical Therapist. BBI is an incredible resource for any movement nerds and corrective exercise specialists! The information is thorough with multiple real world applications. I am looking forward to an in-person Manual Therapist course the second they do one a little bit closer to Virginia ;)

I have taken both the Human Movement Specialist and Certified Personal Trainer certificate programs and have found the value in understanding the how and ways the body moves and functions and from evidence, non-biased, outcome, conceptual, theoretical, and practical approach to helping my clients/patients look better, feel better, and move better.

Over the last years I've returned time and again to Brookbush Institute for stellar coursework as I've worked toward a Human Movement Specialist certification. (I'm currently ACE CPT, and in training with Anatomy Trains for Structural Integration Manual Therapy.) Every Brookbush Institute module is fantastic and each one includes detailed informational videos, written descriptions of how to-do, and, more importantly, why to-do!

I am a 70 yr old chiropractor and no other healthcare provider was able to come up with an exercise protocol particular to my structural and balances and muscle deficits and keep me in the game. And as for continuing education on human skeletal movement, the website is phenomenal full of great exercises for particular mechanical dysfunction.

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Having courses count towards different certifications makes it so users can transition seamlessly from one certification to another. In my case, going from earning the BI CPT to earning the BI HMS was an easy decision and I am proud to have earned both certifications. I have also had the pleasure of going to a Live HMS workshop that was well taught by Instructor Boettcher and that was excellent to see how the methods and techniques are implemented.



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We learn principles in academia, we learn cool new modalities via whatever specialty certification, but BBI really concentrates on the nuances of passive treatment and they do a fantastic job. The format in which BBI instructs soft tissue specialists (DPTs, Chiros, ATs) like myself feels like almost like an apprenticeship. You get a thoroughly detailed explanation of the “why’s”, and a visual comprehension of how to apply. Personally, I believe application is where the good and the great are distinguished.

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This course describes the anatomy and integrated function of the serratus anterior muscle (a.k.a. serratus, S.A., serratus muscle, riblet muscle, rib muscles). This muscle is located on the lateral side of the ribcage, is composed primarily of type I muscle fibers, and crosses the scapulothoracic joint (a.k.a. the shoulder blade, shoulder girdle).

The serratus anterior is the primary protractor of the scapula (shoulder blade), will contribute to upward rotation, and posterior tipping of the scapula, and some research suggests the lower fibers may contribute to depression of the scapula. Further, the serratus anterior is the primary stabilizer of the shoulder girdle, and like the rotator cuff, is likely to exhibit an increase in muscle activity during all motions and exercise for the upper extremity. Additionally, this muscle will eccentrically decelerate scapular retraction, anterior tipping, downward rotation, and potentially elevation. This course also describes the role of the serratus anterior in scapulothoracic, sternoclavicular and acromioclavicular joint arthrokinematics, fascial integration, postural dysfunction, and subsystem integration.

Sports medicine professionals (personal trainers, fitness instructors, physical therapists, massage therapists, chiropractors, occupational therapists, athletic trainers, etc.) must be aware of the integrated anatomy of scapula for the analysis of human movement, and the development of sophisticated exercise programs and therapeutic (rehabilitation) interventions. Further, this course is essential knowledge for future courses discussing the synergistic function of the serratus anterior (e.g. serratus anterior muscle activity increasing to stabilize the scapula during shoulder elevation), injury prevention, and physical rehabilitation (e.g. long thoracic nerve dysfunction, thoracic outlet syndrome, serratus anterior weakness, AC and SC joint pain, shoulder impingement, shoulder pain during humeral elevation, scapular winging, shoulder laxity, etc.) and serratus anterior exercises and techniques for enhancing sports performance (e.g. upper body (arm) stability, strength, power, hypertrophy, etc.)… including why there are better choices than a scapular push-up.

Brookbush Institute’s most recommended techniques for the Serratus Anterior (see videos below):

A cadaver dissection of the serratus anterior muscle with attachment on the ribcage

 Course Description: Serratus Anterior

Introduction

 “notched,” 1660s, from Latin serratus “sawlike, notched like a saw,” from serra “a saw,” of unknown origin. Related: 

 1610s, Latin, literally “former,” comparative of ante “before” (see 

A cadaver dissection of the serratus anterior and long thoracic nerve

Serratus Anterior (Cadaver Dissection) - http://www.med.mun.ca/anatomy/media/ul_innervation/Serratus%20Ant%20Image151.jpg

Attachment and Innervation

Serratus anterior and thoracic muscles on a cadaver dissection cross-section

Attachments & Innervation: Serratus Anterior

Relative Location

The 1st rib attachments for the scalenes and serratus anterior

The 2nd rib attachment for the serratus anterior and posterior scalenes

Where is the Serratus Anterior Located?

Palpation

Palpating the Serratus Anterior

Introduction to the Serratus Anterior

Action

 Protraction, upward rotation, and holding the scapula firmly against the rib cage via posterior tipping and external rotation (the opposite of "scapular winging") (11). Some texts imply that the lower fibers of the serratus anterior may contribute to depression of the scapula; however, several research studies regarding the function of the serratus anterior have not been able to confirm the notion (8). 

Most of the mass of the serratus anterior pulls the inferior angle of the scapula into the rib-cage and out toward the mid-axillary line (3rd set of fibers), highlighting its importance as a posterior tipper and upward rotator of the scapula.

 The serratus anterior may aid in forceful inspiration by displacing the ribs posteriorly (opening the rib cage); however, research suggests the serratus anterior only becomes active during inspiration in very abnormal breathing patterns (8, 11).

 Stabilization of the scapula (acromioclavicular and sternoclavicular joints respectively). The serratus anterior is likely the primary stabilizer of the scapula. It maintains the inferior angle of the scapula on the rib cage, preventing anterior tipping and internal rotation of the scapula which is commonly referred to "as scapular winging" (24).

 Downward rotation, retraction and anterior tipping of the scapula.

 work synergistically to upwardly rotate the scapula.

 work synergistically during protraction of the scapula

 work synergistically to posteriorly tip the scapula (this synergy plays a major role in 

The acromioclavicular joint, joint capsule, ligaments, and cartilage surrounding the scapula

http://www.eorthopod.com/sites/default/files/images/shoulder_distal_clav_osteolysis_anatomy04.jpg

Arthrokinematics

The joint actions and line of pull of the serratus anterior 

Serratus Anterior Muscle Actions 

Fascial Integration

My Fascial Hypothesis: Large fascial sheaths not only play a role in the transmission of mechanical force but may also play a role in dictating the function of muscular synergies. This is likely caused by reducing or increasing tone of invested musculature via reflex arcs formed between mechanoreceptors embedded in the connective tissue and the attached musculature. In this way, my view of fascia differs slightly from noted expert on the subject Tom Myers. I think of these large fascial sheaths (specifically the thoracolumbar fascia, iliotibial band, and abdominal fascial sheath) as nature's “motherboard.” A place for mechanical information to be communicated to the nervous system for more efficient recruitment of the muscular system. Despite having a slightly different philosophy it does not change the fact that fascia plays an important communicative role in the human body and we have Tom Myers to thank for his work.

Image of the fascial system of the body connecting muscles

The fascial network between fascicles of a muscle - http://www.selfcare4rsi.com/images/fascia.jpg

 The tendinous insertion of the lower 5 or 6 serrations of the serratus anterior interdigitate with the 

, sharing fascial sheaths both superficial and deep to these muscles. The relationship between the serratus anterior and external obliques, extending from the rhomboids and across the abdominal sheath to the contralateral internal obliques, has been referred to by some as the "Serape Effect" and is noted by Tom Myers as part of the Spiral Line (SL) (6).

Functionally, the synergy between the serratus anterior and external obliques can be observed during some of the most powerful activities in sport (e.g. throwing a baseball, swinging a bat, or an axe chop), but based on these motions, comparing "function to fascia", we may also need to reconsider the continuation of the superior portion of this fascial line. In the activities noted above, trunk rotation is combined with shoulder adduction/horizontal adduction, shoulder internal rotation, and scapular protraction. These motions are not the result of concentric contraction of the rhomboids, but rather the anterior shoulder musculature. When we take a closer look at the fascial sheath that extends over the serratus anterior, we find that it is a continuation of the clavipectoral and axillary fascia. The clavipectoral and axillary fascia are invested by fascia from the anterior shoulder musculature - the 

. Perhaps it is not a "serape effect", or a "spiral line" but rather an extension of the 

 that includes some of the most powerful anterior shoulder muscles. More research and attention should be given to this fascial network.

A more accurate depiction of fascial syndergy between the serratus anterior, external oblqiues and anterior adductors

Could the black lines in the picture on the right be a more accurate depiction of this fascial synergy? - http://www.innovative-results.com/wp-content/uploads/2014/01/planes-of-movement.jpg

I tried to find research that examined the deeper layers of fascia that extend under the serratus anterior, invest in the periosteum of the ribs and intercostals, and potentially continue to the various layers of core fascia. Determining the potential relationship between deeper layers of the core and the serratus anterior may inspire new ideas regarding the serratus anterior, rib motion, breathing, and core function (for example, a relationship between the serratus anterior, the deepest layers of core fascia, and the diaphragm may imply that serratus anterior function is closely tied to breathing and optimal rib motion). Unfortunately, I could not find any information regarding how the layers of fascia between the 

 and transverse abdominis, and the transverse abdominis and periosteum continue once they meet the rib cage.

As mentioned above the first set of fibers of the serratus anterior insert into the first and second rib and border the middle and posterior scalenes. Could this be evidence of a fascial relationship between the scalenes and serratus anterior related to rib motion and breathing, or cervicothoracic junction and scapular mechanics? In a study by Helgadottir et. al., a relationship was found between neck pain and a reduction in serratus anterior activity (20). While a fascial synergy would between the two seem to elicit contrary activity (an increase in serratus anterior activity leads to a decrease in scalene activity and visa-versa), it may be worth exploring the relationships between cervical and/or scapular dyskinesis, prevertebral cervical fascia, 1st, and 2nd rib mobility, scalene activity, and 

The serratus anterior aligning with the external obliques in a cadaver dissection

Notice how the Serratus Anterior and External Obliques "weave" into one another - http://www.med.mun.ca/anatomy/media/ul_innervation/Lat.%20Dorsi%203%20Image132.jpg

 The insertion of the serratus anterior is abutted by the subscapularis laterally, the 

 inferiorly, and in some individuals the serratus anterior may actually overlap the insertion of the 

 (on the anterior side of the scapula) (8).

The near-continuous fiber direction observed from serratus anterior to rhomboids and the shared attachment on the medial border of the scapula have inspired a variety of notions on what relationship may exist between these two muscles (e.g. "the serape effect" and "the spiral line (6)"). These two muscles are functional antagonists, making a synergistic relationship less likely than an antagonistic relationship; however, this would not be the only fascial relationship that included antagonists. The one shared "joint action" of these two muscles is external rotation of the scapula, which may imply that even antagonistic activity is important in maintaining the scapula against the rib cage and enhancing scapulothoracic stabilization. Supporting this notion, Reed et al. found that activity of both the serratus anterior and 

 increased as load increased during elevation of the arm (25).

The subscapularis and serratus anterior share an attachment at the anteromedial border of the scapula. Although the serratus anterior is responsible for scapular motion and the subscapularis is responsible for glenohumeral (shoulder) motion there does seem to be a relationship between the two. I have mentioned in videos and articles regarding 

 that the subscapularis may become synergistically dominant for an inhibited serratus anterior. This notion is based on clinical findings (no research to support this notion at present) of serratus anterior inhibition and/or weakness being paired with subscapularis over-activity, trigger points, and a loss of extensibility. Perhaps this is a less than optimal way to make-up for the loss in scapular stabilization. The relationship could be mere coincidence, related to the most common alterations in muscle activity observed in 

, but consideration of fascial relationship is worth exploration.

As discussed above, a relationship between under-activity of the serratus anterior and neck pain was found in the study by Helgadottir et. al (20). Another potential contributor to this relationship may be fascial continuity between the 

 and the first set of fibers of the serratus anterior. My guess is that this relationship would not be present in all individuals, as relatively few individuals exhibit an overlap between 

 and serratus anterior fibers (8). More research should be done to determine if there is sufficient fascial continuity to examine a relationship, regardless of overlap. If may imply an interesting synergy between the 

, posterior and middle scalenes, and the first set of fibers of the serratus anterior.

There may be a weak fascial relationship between the 

 and the serratus anterior at the inferior angle of the scapula. Any interaction would further support the extension of the 

 discussed above. However, in some individuals the latissimus dorsi does not actually attach to the scapula, simply coursing over it, and I could not find evidence of fibers of the 

 extending to the anterior surface of the inferior angle of the scapula.

The serratus anterior fiber alignment in comparison with the rhomboids, and levator scapula

Note the continuity of fiber direction and imagine the overlapping attachments of the serratus anterior, rhomboids and levator scapulae. -http://biowiki.ucdavis.edu/TextMaps/OpenStax_Anatomy_and_Physiology/Unit_2%3A_Support_and_Movement/11%3A_The_Muscular_System/11.5%3A_Muscles_of_the_Pectoral_Girdle_and_Upper_Limbs

Behavior in Postural Dysfunction

 by many clinicians, texts and studies (1, 2, 4, 7, 8, 11, 17, 20, 26).

The serratus anterior is most often long and under-active in those with 

. Scavozzo et al (17) found that swimmers with symptoms of shoulder impingement exhibited less than half the normal activity of the serratus anterior during the pull-through phase of stroke, and Helgadottir et. al (20) found reduced serratus anterior activity in those with neck pain, and Day et al. even found that lateral epicondylalgia reduced serratus anterior activity (26). It has been hypothesized that inhibition of the serratus anterior may result in, or be the result of synergistic dominance of the 

. This change in muscle activity may be a primary cause of the excessive anterior tipping and downward rotation noted in those with 

. Clinically, I have also found that a relationship exists between thoracic mobility and scapular muscle activity (including the serratus anterior). That is, thoracic mobilization may enhance the effectiveness of 

), and thoracic spine stiffness may reduce the effectiveness of soft tissue and muscle activation techniques. Some evidence exists to support this relationship, as a correlation between a thoracic kyphosis and shoulder impingement was found in a study by Otoshi et al.

Lumbo Pelvic Hip Complex Dysfunction (LPHCD)

 the serratus anterior plays no significant role.

, the serratus anterior has a propensity toward under-activity and lengthening in 

. This implies that activation, integration, and strengthening techniques for the serratus anterior (and potentially self-administered thoracic mobilizations) should be part of a human movement professional's repertoire. Further, AC, SC, and thoracic mobilization techniques may aid in optimizing scapulothoracic kinematics and should be part of the repertoire of any licensed professional (PT, ATC, DC, OT, DO).

Impingement of Brachial Plexus (Thoracic Outlet Syndrome?)

Impingement of Axillary Artery (Thoracic Outlet Syndrome?)

Cervical Radiculopathy (Brachial plexus impingement)

Signs of Altered Length/Tension and Tone:

Serratus Anterior Manual Muscle Test (MMT)

Inability to raise the arm above 100º of shoulder elevation

Palpation results in tenderness and may result in radiating symptoms.

Common trigger points and referral pain patterns of the serratus anterior muscle

Postural Dysfunction and the Serratus Anterior

Serratus Anterior Isolated Activation

Serratus Anterior  Isolated Activation Progression

Serratus Anterior Reactive Integration

Exercises and Techniques for the Serratus Anterior

Phillip Page, Clare Frank, Robert Lardner, 

Assessment and Treatment of Muscle Imbalance: The Janda Approach

NASM Essentials of Corrective Exercise Training

NASM Essentials of Personal Training: 4th Edition

Diagnoses and Treatment of Movement Impairment Syndromes,

David G. Simons, Janet Travell, Lois S. Simons, 

Travell & Simmons’ Myofascial Pain and Dysfunction, The Trigger Point Manual, Volume 1. Upper Half of Body: Second Edition

Joint Structure and Function: A Comprehensive Analysis: Fifth Edition

Florence Peterson Kendall, Elizabeth Kendall McCreary, Patricia Geise Provance, Mary McIntyre Rodgers, William Anthony Romani

Manipulative Therapy: Musuloskeletal Medicine

Carolyn Richardson, Paul Hodges, Julie Hides. Therapeutic Exercise for Lumbo Pelvic Stabilization – A Motor Control Approach for the Treatment and Prevention of Low Back Pain: 2nd Edition (c) Elsevier Limited, 2004

Lawrence, R. L., Braman, J. P., Laprade, R. F., & Ludewig, P. M. (2014). Comparison of 3-dimensional shoulder complex kinematics in individuals with and without shoulder pain, part 1: sternoclavicular, acromioclavicular, and scapulothoracic joints. 

journal of orthopaedic & sports physical therapy

Scovazzo, M.L., Browne, A., Pink, M., Jobe, F.W., and Kerrigan, J. (1991). The painful shoulder during freestyle swimming: An electromyographic cinematographic analysis of twelve muscles. 

Glousman R, Jobe F, Tibone J et al. Dynamic Electromyographic Analysis of the Throwing Shoulder with Glenohumeral Instability. J Bone Joint 

Ludewig PM, Cook TM. Alterations in Shoulder Kinematics and Associated Muscle Activity in People with Symptoms of Shoulder Impingement. 

Helgadottir, H., Kristjansson, E., Einarsson, E., Karduna, A., & Jonsson, H. (2011). Altered activity of the serratus anterior during unilateral arm elevation in patients with cervical disorders. 

Journal of electromyography and kinesiology

Hardwick DH, Beebe JA, McDonnell MK, Lang CE. (2006). A comparison of serratus anterior muscle activation during a wall slide exercise and other traditional exercises. 

Journal of Orthopaedic & Sports Physical Therapy

Oladipo GS, Aigbogun Jr EO, Akani GL. (2015). Angle at the medial border: the spinovertebral angle and its significance. 

Nasu H, Yamaguchi K, Nimura A, Akita K. (2012). An anatomic study of structure and innervation of the serratus anterior muscle. Surg Radiol Anat. 34:921-928.

Park K, Cynn H, Yi C, Kwon O. (2013). Effect of isometric horizontal abduction on pectoralis major and serratus anterior EMG activity during three exercises in subjects with scapular winging. Journal of Electromyography and Kinesiology. 23(2): 462-468.

Reed D, Cathers I, Halaki M, Ginn KA. (2015). Does load influence shoulder muscle recruitment patterns during scapular plane abduction? Journal of Science and Medicine in Sport.

Day, JM, Bush H, Nitz AJ, Uhl TL. (2015). Scapular muscle performance in individuals with lateral epicondylalgia. JOSPT. 45(5): 414-424.

Bibliography

Questions, comments, and criticisms are welcome and encouraged.

Serratus Anterior

Related Courses:

Course Description: Serratus Anterior

Introduction to the Serratus Anterior
3 Sub Sections

Serratus Anterior Muscle Actions
1 Sub Section

Fascial Integration

Postural Dysfunction and the Serratus Anterior

Exercises and Techniques for the Serratus Anterior
3 Sub Sections

Bibliography

Related Courses:

Comments

Guest

Serratus Anterior

Related Courses:

Course Description: Serratus Anterior

Introduction to the Serratus Anterior3 Sub Sections

Serratus Anterior Muscle Actions 1 Sub Section

Fascial Integration

Postural Dysfunction and the Serratus Anterior

Exercises and Techniques for the Serratus Anterior3 Sub Sections

Bibliography

Related Courses:

Comments

Guest

Introduction to the Serratus Anterior
3 Sub Sections

Serratus Anterior Muscle Actions
1 Sub Section

Exercises and Techniques for the Serratus Anterior
3 Sub Sections