Best Exercises for Serratus Anterior, Levator Scapulae and Rhomboids (Part 2)

This is Part 2 of the Evidence-Based Strength Training Series. In the first article, we looked at the often-neglected scapulothoracic muscles, their functions and the best exercises to recruit them.

In the article:

• Scapulothoracic Muscles and Pain

• EMG Activity and Exercise Goals

• From Biomechanics to Exercises

• Choosing the Best Exercise

• [Video] Rotator Cuff Tear

Scapulothoracic Muscles and Pain

As I mentioned in Part 1, weakness or poor neuromuscular control of the periscapular muscles has been implicated in subacromial impingement^1,2, lateral epicondylalgia^3-5, cervicogenic headache⁶, and neck pain^7,8.

Specifically, insidious onset of neck pain and whiplash-associated disorder (WAD) have been linked with a significant delay in and shorter duration of serratus anterior activity bilaterally during arm elevation⁹. A similar study found decreased serrates anterior activation in individuals with acromioclavicular osteoarthritis and rotator cuff disease.¹⁰

Although a cause-and-effect relationship cannot be confirmed, this preliminary evidence still lends support for targeting the periscapular muscles in individuals with neck or shoulder pain.

EMG Activity and Exercise Goals

According to Reiman et al.¹¹ and Escamilla et al.¹², moderate EMG activation (21-40% MVIC) is best used to facilitate endurance and neuromuscular re-education; high activation (41-60+% MVIC) promotes strength gains.

From Biomechanics to Exercises

Serratus Anterior

Primary Function: scapular upward rotation, external rotation, posterior tilt at the acromioclavicular joint, protraction of the clavicle at the sternoclavicular joint.

Origin: External surfaces of lateral aspect of 1st-8th ribs

Insertion: Anterior surface of medial border of scapula

The SA is often activated with scapular protraction. The exercises yielding the highest MVIC for the serratus anterior include:

• dynamic hug¹³

• push-up plus¹³

• scaption with external rotation¹⁴

• diagonal PNF (shoulder flexion, horizontal flexion, external rotation)¹⁵

• shoulder abduction in scapular plane above 120 degrees¹⁵

The upper trapezius (UT) often compensates for a weak or inhibited serratus anterior, so its beneficial to selectively activate the SA in lieu of the UT. According to Cools and colleagues, the best SA:UT ratio is achieved in:

• high row

• forward shoulder flexion

• scaption with external rotation¹⁴

Serratus AnteriorProne Push Up with Plus Serratus AnteriorDynamic Hug with Resistance

[Table] MVIC values for SA exercises

Levator Scapulae

Primary Functions: scapular elevation, glenoid cavity inferior tilt through upward scapular rotation

Origin: Posterior tubercles of transverse processes of C1-C4 vertebrae

Insertion: Medial border of scapula superior to root of scapular spine

These muscles have received little attention in the literature compared the SA or trapezius. In a study, Moseley and colleagues discovered that the levator scapulae achieves the highest activity in:

• rowing

• horizontal abduction

• shrug

• horizontal abduction with ER

• prone shoulder extension¹⁶

[Table] MVIC values for Levator Scapulae exercises

Rhomboids

Primary Functions: Retraction of the scapula; upward rotation to depress glenoid cavity; scapular attachment to thoracic wall

Origin: nuchal ligament; spinous processes of C7, T1 and T2-T5 vertebrae

Insertion: smooth triangular area at medial end of scapular spine; medial border of scapula from level of spine to inferior angle

The rhomboids achieve the highest MVIC during:

• ER at 90 of abduction¹⁷

• ER at 0 of abduction¹⁷

• horizontal abduction¹⁶

• shoulder extension¹⁷

• scaption¹⁶

Levator ScapulaeProne Shoulder Row RhomboidShoulder External Rotation at 90 Abduction withDumbbell

[Table] MVIC values for rhomboid muscle exercises

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Choosing the Best Exercise

These studies give us a glimpse into properly selecting exercises, yet very few exercises have been or will ever be studied.

When choosing an exercise for your patient, be sure to consider:

• the biomechanics of the movement,

• current evidence for or against the exercise,

• your patient's presentation and goals for treatment.

• aggravating movement(s) or comparable signs

For more information on treating shoulder dysfunction, check out Eric Hegedus's course Evidence-Based Treatment of the Shoulder: An Update.