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Therapist Notes – Serratus Posterior Superior

Serratus posterior superior produces an ache under the shoulder blade that is easily confused with the referral patterns of other muscles. It is involved in shoulder pain more than 90% of the time. It is distinctive when it produces the associated elbow and lateral wrist pain.

Serratus posterior superior acts as a 5th scalene muscle. It has a similar location, attaching to the spine and extending out to pull up on the ribs to
assist with inhalation. It has similar attachments and actions. Also, it produces a very similar referral pattern. It should always be checked when scalenes are involved.

Start by Understanding the Anatomy.
About the coloring of the illustrations…

This muscle is made of thin, flat strips that help to lift our ribs as we breather. Learn more in this post about serratus posterior superior.


Breathing while slouched forward perpetuates the constant pain generated in this pattern. Because of this, the treatment approach usually involves mobilizing joints first. Serratus posterior superior is strongly governed by the costovertebral joints of the upper thoracic spine. These fixations are almost always associated with locally displaced vertebrae, especially the shearing of C7 and the upper thoracics in Forward-Head posture. It is hard to get a sustained release of this muscle unless you can free up the displaced rib heads with lamina groove work or some other soft joint mobilization. Clients also need help with posture so that they do not naturally slouch while seated. Soft tissue release follows joint work. Then, help with changes in postural habits and exercises that counter Forward Head Posture.

Be aware that, although the common complaint of this trigger point is pain under the shoulder blade, it is not always the case. Many people have blocked out the pain under the shoulder and start complaining when the wrist or elbow bothers them. When asked, they often remark that the pain under the shoulder is constant and that they ignore it.


Treatment Sequencing

Get the Head Over the Shoulders

When the atlas is wedged anteriorly, Forward-Head Posture is perpetuated. When that occurs, it is difficult to take tension off this muscle. Get the upper cervicals mobile under the occiput. It is hard to do that with the lamina groove routine listed below. Use one of the routines for mobilizing the atlas or releasing the suboccipital muscles.

Release the Tension with Gentle Joint Work

Mobilize the local rib heads. These trigger points are strongly governed by the local costovertebral joints. Make sure the rib heads are gentle lifted off the transverse processes.

While you are here, slip your fingers under the SCM and onto the lower vertebrae. Free the lower cervical vertebrae that are sheared forward. Serratus posterior superior often relaxes as this joint progresses.

Free the Nerves and Joints More Completely

Direct treatment of the area will be easier and more effective, after the lamina groove protocol. Prepare the area by loosening the spine and costovertebral joints. Pay extra attention to the vertebrae around the base of the neck, where serratus posterior superior connects.

This NMT protocol is great for mobilizing vertebrae and melting down the lamina groove. It starts with the sub-occipital area, which helps with Forward-Head Posture.

Direct Work on the Muscle

Review this routine on the treatment of the Rhomboids and Serratus Posterior Superior from The workbook of Classical Neuromuscular Therapy.

Self-Care is Important

Getting a good home program can be essential to long term success. There are great strategies in this post. Changing their seated posture and releasing the fixated joints are included.



This site is undergoing changes. Starting in early 2020, we began improving the format. We are also adding more extensive self-care, illustrations, therapist notes, anatomy, and protocols. We appreciate your input and feedback. You will see us adding posts and updating older posts as time permits.


Weekly Featured Post

This post shows you how to press out the trigger points and stretch the infraspinatus muscle. It’s a small muscle on the back of the shoulder but creates a number of problems, including:

  • shoulder pain when sleeping
  • loss of grip strength
  • upper neck pain
  • pain along the inside edge of the shoulder blade

Tony Preston has a practice in Atlanta, Georgia where he sees clients. He has written and taught about anatomy, trigger points, and cranial therapies since the mid-90s.

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*This site is undergoing major changes. We are reformatting and expanding the posts to make it easier to read. The result will also be more accessible and
will include more patterns with better self-care. In the meanwhile, there may be inconsistency in formatting, content presentation, and readability. Until we get older posts updated, please excuse our mess.

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