Can’t Reach Overhead? Pain Reaching Overhead? Check Your Serratus Anterior

Reaching overhead is one of the most important movements in daily life. It is also crucial for baseball and other overhead sports. Research by Wilk, et al. showed that decreased shoulder flexion before the season increased elbow injury risk during the season for major and minor league pitchers. I have spoken before about how elbow injuries are increasing in baseball, and assessing the joints above and below are important in injury treatment and prevention.

The questions to ask are: how do we assess overhead motion and what do we do to fix it?

First, assessing overhead motion can be done in a number of ways. The simplest way is just standing and reaching your arm as high as you can. This looks at your gross movement capabilities while using all of the strategies available to you. By using all of your strategies, I mean that you can arch your back, shrug your shoulders, and do any other compensations you like in order to gain range. To give you an example of this, slouch down as if you have terrible posture and then reach as high as you can. Now sit up tall and reach up as high as you can, you can probably reach a lot higher when you sit with an extended posture. It is not a bad thing to reach further, but it is important to understand. If you have difficulty extending your spine, then your range of motion may be limited. Conversely, if you are very flexible in your spine, then your shoulder range of motion could be limited and you would have no idea because your back is able to compensate.

So, how can we measure shoulder range of motion by itself? We need to get into a position where we can control all of the other joints and take them out of the equation. This involves lying on your back. Relaxing your neck and back muscles will provide for a better estimation of shoulder mobility. A key with this test is to look for aberrant movements. Commonly, people will raise their head up to compensate for tight neck muscles. If you notice your head coming off of the ground, try to gently press it down. Consider yourself as reaching the end of your mobility if you are unable to keep your head down. Another common compensation involves your low back arching upwards. This creates more extension in your thoracic spine and is typically a result of tightness in your latissimus dorsi. Try to keep your low back relaxed and follow the same rule: if you are unable to stop your low back from arching, you have reached your mobility limits.

If you perform this test and notice that you do have full range of motion, but you still struggle in raising your arm overhead, then you have an active mobility problem. This means that your muscles are not supporting your movement. Your body has the necessary mobility, but it is unable to access it. Many people in this situation make the mistake of stretching to fix this problem. As I mentioned, the muscles have the flexibility, but they do not have the strength. The answer does not lie in mobility, but instead strengthening.

Shoulder Impingement

Shoulder impingement is one of the most common diagnoses for shoulder pain as I touched on here. There are different types of shoulder impingement, and it is important to note if there is active or passive impingement. If you are unable to stretch your arm fully overhead while lying on your back, then there is a structural reason for your limitation. The structural reason could be muscle tightness, joint restriction, a bony block, or something else. If you are able to reach fully overhead while lying on your back, then there is an active impingement. The muscles in your shoulder are not allowing you to reach overhead. This can often be thought of as a rotator cuff issue, but there is a neglected muscle that I find is frequently the culprit: the serratus anterior.

Serratus Anterior

The serratus anterior is a difficult to see muscle, but here is an image of it:

Anatomography, CC BY-SA 2.1 JP <https://creativecommons.org/licenses/by-sa/2.1/jp/deed.en>, via Wikimedia Commons

The serratus anterior originates from the side of your first 8 ribs and runs to the front of the inside edge of your scapula. Its function is to protract the scapula, or rotate it around your rib cage. It works synergistically with the lower trapezius, as shown in this image courtesy of zachdechant.com

This movement is important because when you reach overhead, your scapula needs to rotate up and around your ribs to allow for the movement to occur. Try to raise your arm overhead while squeezing your shoulder blades behind you. You probably feel tension somewhere in your shoulder. As a result of limited scapular rotation, the stress goes to the rotator cuff muscles and the shoulder joint to try and create more movement. If they are unable, then you end up with impingement symptoms. Oftentimes, we diagnose this condition as a rotator cuff issue or shoulder impingement, when really the shoulder is dealing with the symptoms due to poor mobility of the scapula.

Improve Overhead Mobility

So, what can you do to improve your overhead mobility? Let’s talk about a few exercises to help with serratus anterior strengthening as well as overhead mobility.

The first image is courtesy of functionalmovement.com and involves increasing thoracic extension. While this can be beneficial in itself as I mentioned before, this also creates a better angle for the serratus anterior. A slouched position makes it more difficult to move the scapula around the rib cage, as there is significant expansion in the back that makes movement difficult. This allows for a slightly flatter surface on which the scapula can move. This exercise can be done frequently, but it is best to do before other exercises, as mobility gains from foam rolling can be brief.

The next image comes from medium.com and also involves a foam roller. This time, you place the roller on a wall, put your elbows on it, and roll it towards the sky while maintaining contact. This provides some thoracic extension, but it forces you to engage your serratus anterior to keep contact with the wall. You are essentially teaching your shoulder blades to rotate up and around in order to propel the foam roller. This is a great starting exercise to determine what scapular mobility should feel like. This gives you a better idea for future exercises.

This image from researchgate.net shows a “push-up plus”. This is a normal push-up with extra protraction to engage the serratus anterior at the end of the motion. Oftentimes, people let their shoulder blades remain squeezed together during push-ups, which limits serratus anterior activity. The goal of this is to create greater scapular movement and control through the range of the exercise, with an emphasis on the top portion. This is a surprisingly difficult exercise and if it is too hard, you can start with your hands elevated.

This exercise is to address muscular endurance with a carry. The image is courtesy of peerj.com and comes from a study by Driveline Baseball showing superior activation of the serratus anterior while holding a kettlebell at a 45 degree angle to the body instead of straight out to the side. Maintaining this position with your arm and walking forces the serratus anterior to remain engaged, allowing for improved endurance. It is important to train muscles for overall strength but also endurance, and this exercise addresses the latter.

https://pixnio.com/sport/bodybuilding/performing-what-are-known-as-standing-overhead-barbell-presses

The final exercise is a simple overhead press. Now that you have an understanding of what proper scapular motion should feel like, it is important to load the movement with a functional task. It can be easier to start with dumbbells so that you can focus on moving them around as needed, but eventual transition to a barbell is helpful. This allows for increased weight while also simulating a difficult object you may have to lift. The mobility work performed previously will be accentuated with loaded movement into the range to help it stick. Many people make the mistake of simply performing mobility exercises with no follow up strengthening in the new range.

These are just a few exercises that I like to use with clients that struggle reaching overhead actively. It is important to tailor them to specific needs. I work with many baseball players, so full overhead range of motion is crucial to decrease injury risk and allow for optimal performance. The average person probably does not need full shoulder range of motion, but it is important to maintain enough to ensure good quality of life and ease with your daily activities.

As always, if you are suffering from pain, nerve symptoms (numbness, tingling, or weakness), or anything else significant, please see a healthcare provider. This blog is meant to be educational and is not a substitute for medical advice.

Hopefully you learned something about overhead mobility, assessing your mobility, and the function and training of the serratus anterior. The goal of any practitioner is to educate and empower your client, and that is my hope with this blog. If you found this helpful, please share it with someone. We hope to continue to grow and help people better understand how our bodies move and work. If you are in the Sterling, Virginia area and would like to work with me or you have any questions, please email me at danny@eclipsewellnessnova.com or follow me on Instagram or Twitter @drdannydpt.