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Serratus Anterior Muscle Activity During Selected Rehabilitation Exercises* Michael J 0363-5465/99/2727-0784$02.00/0 THE AMERICAN JOURNAL OF SPORTS MEDICINE, Vol. 27, No. 6 © 1999 American Orthopaedic Society for Sports Medicine Serratus Anterior Muscle Activity During Selected Rehabilitation Exercises* Michael J. Decker,† MS, Robert A. Hintermeister, PhD, Kenneth J. Faber, MD, and Richard J. Hawkins, MD From the Steadman Hawkins, Sports Medicine Foundation, Vail, Colorado ABSTRACT Proper positioning of the humerus in the glenoid cavity, known as scapulohumeral rhythm,6 is critical to the The purpose of this study was to document the elec- proper function of the glenohumeral joint during overhead tromyographic activity and applied resistance associ- motion. A disturbance in normal scapulohumeral rhythm ated with eight scapulohumeral exercises performed may cause inappropriate positioning of the glenoid rela- below shoulder height. We used this information to tive to the humeral head, resulting in injury.16,18,22 design a continuum of serratus anterior muscle exer- One of the primary muscles responsible for maintaining cises for progressive rehabilitation or training. Five normal rhythm and shoulder motion is the serratus ante- muscles in 20 healthy subjects were studied with sur- rior.8,32 Lack of strength or endurance in this muscle face electrodes for the following exercises: shoulder allows the scapula to rest in a downwardly rotated posi- extension, forward punch, serratus anterior punch, dy- tion, causing the inferior border to become more promi- namic hug, scaption (with external rotation), press-up, nent (scapular winging).32 Scapular winging may precip- push-up plus, and knee push-up plus. Electromyo- itate or contribute to persistent symptoms in patients with graphic data were collected from the middle serratus orthopaedic shoulder abnormalities.19 Thus, the injured anterior, upper and middle trapezius, and anterior and shoulder with subsequent immobilization or disuse may posterior deltoid muscles. Each exercise was parti- benefit from a rehabilitation program that reconditions tioned into phases of increasing and decreasing force the serratus anterior muscle. and analyzed for average and peak electromyographic Shoulder exercises intended to strengthen the serratus amplitude. Resistance was provided by body weight, anterior muscle and other scapular stabilizers have been in- an elastic cord, or dumbbells. The serratus anterior cluded in shoulder rehabilitation protocols.4,16,23,25,26,29,34 Ex- punch, scaption, dynamic hug, knee push-up plus, and ercise selection has been based on EMG data4,23,25,33 or clinical push-up plus exercises consistently elicited serratus experience.26,29,34 Several researchers have recommended anterior muscle activity greater than 20% maximal vol- that exercises be performed with the arm below 90° of humeral untary contraction. The exercises that maintained an elevation during the initial stages of rehabilitation to prevent upwardly rotated scapula while accentuating scapular excessive strain on the rotator cuff and shoulder liga- protraction, such as the push-up plus and the newly ments.15,23,27,32 Despite these recommendations, a progres- designed dynamic hug, elicited the greatest electro- sion of shoulder rehabilitation exercises that specifically target myographic activity from the serratus anterior muscle. the serratus anterior muscle while constraining humeral ele- vation below shoulder height has not, to our knowledge, been investigated. The purpose of this study was to document the Normal shoulder motion results from a complex interplay EMG activity and applied resistance associated with eight of the scapulohumeral, acromioclavicular, sternoclavicu- scapulohumeral exercises performed below shoulder height lar, and scapulothoracic articulations. The coordination of that target the serratus anterior muscle and to design a con- these articulations provides the shoulder with an ample tinuum of serratus anterior muscle exercises for progressive range of motion necessary for overhead sporting activities. rehabilitation or training. * Presented at the the American College of Sports Medicine annual con- MATERIALS AND METHODS ference, Denver, Colorado, May 1997. † Address correspondence and reprint requests to Michael J. Decker, MS, Subject Preparation Steadman Hawkins Sports Medicine Foundation, 181 West Meadow Drive, Suite 1000, Vail, CO 81657. 6 6 No author or related institution has received any financial benefit from Twenty male subjects (age, 30.4 5.1 years [average research in this study. See “Acknowledgements” for funding information. SD]; height, 1.8 6 0.1 meters; weight, 80.1 6 9.6 kg) with 784 Vol. 27, No. 6, 1999 Serratus Anterior Muscle Activity and Shoulder Rehabilitation 785 no history of shoulder injury gave their written informed na). The input impedance of the EMG amplifier was less consent to participate in this study. Before testing, all than 10 megaohms, with a common-mode rejection ratio of subjects participated in an orientation session to practice 85 dB and a gain of 1000. the exercise techniques and maximum voluntary contrac- To assist in the delineation of exercise phases, a lateral tion (MVC) protocols. view of each subject was recorded using a 30-Hz video Pregelled, silver-silver chloride bipolar surface elec- camera. A manual timing signal was recorded with the trodes (NDM, Dayton, Ohio) were placed over five mus- Myosoft software and video camera, providing for synchro- cles: the upper trapezius, middle trapezius, anterior del- nization of video and EMG data. toid, posterior deltoid, and middle serratus anterior. All exercises were completed in a slow, controlled man- Surface electrodes were used because they are noninva- ner with the aid of a metronome. Each phase of the exer- sive and provide a reliable means to access the greatest cises was performed at 54 beats per minute (bpm), except 10 portrayal of motor unit activity of a superficial muscle. the press-up (60 bpm), shoulder extension (100 bpm), and The electrodes were placed according to the method de- serratus anterior punch (100 bpm) exercises. The exer- 3 scribed by Basmajian and DeLuca, with an interelectrode cises using the elastic resistance device for resistance distance of approximately 25 mm. Electrode placements were performed at a distance where the subject could 12 are described in Table 1 and in a previous study. Elec- perform no more than 10 repetitions while maintaining trode placements were confirmed from a manual muscle consistent metronome speed. The exercise order was ran- test of the primary muscle. domly selected for the first subject and subsequently bal- anced to eliminate any order effects. The exercises were Experimental Protocol performed as follows. The push-up plus began with the subject in a prone On the day of testing, the subject warmed up by walking position with the hands shoulder-width apart and the on a treadmill at a self-selected pace for 5 minutes. The chest near the ground.25 testing session began with a series of five isometric MVCs The subject then extended his for each muscle. The 3-second maximum contractions elbows to a standard push-up position and continued to were interspersed with 3 to 5 seconds of rest. Maximum rise up by protracting the scapula. The subject returned to voluntary contraction protocols for all muscles are de- the starting position by retracting the scapula and flexing scribed in Table 1. All MVCs were performed in a joint the elbows. configuration that maximized EMG activity. Resistance The knee push-up plus, a modification of the push-up was provided by chains mounted to a wall and aligned plus, was performed exactly like the push-up plus except parallel to the line of pull. A consistent shoulder joint that body weight was supported by the hands and knees, position was ensured by placing rigid wedges between the rather than the hands and feet. trunk and arm. The press-up was performed from a seated position, Applied force and EMG data were collected (1000 Hz) with feet off the floor, hands at the level of the buttocks, for eight exercises that were performed below shoulder and the trunk and elbows slightly flexed.31 The subject height. Applied force was measured with a force plate then slowly raised his body up off the chair by straighten- (Bertec Corp., Columbus, Ohio) or a force transducer (En- ing his arms. The subject held this position for 3 seconds tran Devices Inc., Fairfield, New Jersey) (maximal range, and then slowly returned to the starting position. 61115 N) placed in series with an elastic resistance device Shoulder extension was performed while the subject (Body Lines, Innovation Sports, Irvine, California). The stood with his chest facing the wall, knees slightly bent, EMG data (bandwidth 10 to 2000 Hz) were collected using and feet shoulder-width apart in a split stance.13,23 The Myosoft software (Noraxon USA Inc., Scottsdale, Arizo- lead leg was the leg opposite the hand gripping the elastic TABLE 1 Muscles Tested, Electrode Position, and MVC Protocol Muscle Electrode position MVC joint position MVC Action Upper trapezius At the angle of the neck and shoulder, over Arms fully extended, subject Shoulder shrug the belly of the muscle in line with the standing on two chains grasping (Scapular muscle fibers. the handles at mid-thigh. elevation and retraction) Middle trapezius Centered vertically between the medial Elbow flexed 15°, shoulder flexed Scapular border of the scapula and the spines of 90° and internally rotated 45°. retraction the thoracic vertebrae (T-1 to T-6). Anterior deltoid Two to three finger-breadths below the Elbow flexed to 90°, no shoulder Shoulder acromion process, over the muscle belly, flexion. flexion in line with the fibers. Posterior deltoid Two finger-widths behind the angle of the Elbow flexed 90°, shoulder abducted Shoulder acromion, over the muscle belly, in line 45°, and internally rotated 45°. extension with the fibers. Serratus anterior Below the axilla, anterior to the latissimus, Elbow flexed 45°, shoulder abducted Scapular placed vertically over the ribs 4–6. 75° and internally rotated 45°. protraction 786 Decker et al. American Journal of Sports Medicine resistance device, and the other leg was behind the mid- line of the sagittal plane.
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