Physiotherapy Theory and Practice, 22(1):33
42, 2006

Copyright # Taylor & Francis LLC

ISSN: 0959-3985 print/1521-0510 online
DOI: 10.1080/09593980500422461

Reliability and smallest detectable change

determination for serratus anterior muscle strength
and endurance tests
S. Sharon Wang, PhD, PT, OCS,1 Scott O. Normile, MS, PT,2
1
and Brandon T. Lawshe, MS, PT, ATC3
Texas Woman’s University, School of Physical Therapy, Dallas, TX, USA
2
Methodist Dallas Medical Center, Center for Occupational Medicine, Dallas, TX, USA
3
Ben Hogan Sports Institute, Fort Worth, TX, USA

The purposes of this study were to determine inter-tester reliability, one-week test
retest reliability
and smallest detectable difference (SDD) of serratus anterior muscle strength and endurance tests.
Asymptomatic subjects were tested on an apparatus designed by the investigators. During strength test-
ing, subjects performed isometric contractions recorded by a hand-held dynamometer. For endurance
testing, subjects held a dumbbell of 15% of their body weight and performed repetitions until they
became fatigued. Intraclass correlation coefficients (ICC) for the strength test revealed good inter-
tester reliability (ICC2,3 ¼ .90
.93) and good one-week test
retest reliability (ICC2,3 ¼ .83
.89).
For the endurance test, ICCs showed good inter-tester reliability (ICC2,1 ¼ .71
.76) but moderate
one-week test
retest reliability (ICC2,1 ¼ .59
.62). The SDDs at 68% confidence level ranged from
22.7 to 39.2 newtons for the strength test, and 11 to 20 repetitions for the endurance test. In summary,
the technique used in the study is reliable for quantifying the SA muscle strength.

Introduction linked to shoulder disorders (Kuhn, Plancher,

Normal function of the serratus anterior
muscle is essential in maintaining proper scapulo-
humeral rhythm during arm elevation (Decker,
Hintermeister, Faber, and Hawkins, 1999;
Warner and Navarro, 1998; Wiater and Flatow,
1999). When serratus anterior muscle strength is
insufficient, scapular upward rotation and pro-
traction is inadequate, making shoulder impinge-
ment more likely to occur (Kuhn, Plancher, and
Hawkins, 1995; Wiater and Flatow, 1999). In
addition, weakness of the serratus anterior is often
associated with scapular winging, which is also
and Hawkins, 1995; Warner and Navarro, 1998).
Although clinicians understand the impor-
tance of the serratus anterior muscle to normal
shoulder function, assessment of serratus anterior
muscle strength presents multiple problems. The
first problem is the difficulty of determining the
optimal position to test serratus anterior strength
without recruiting other muscles. Several differ-
ent test positions are advocated for testing
serratus anterior muscle strength (Clarkson,
2000; Hislop and Montgomery, 1995; Kendall,
McCreary, and Provance, 1993). Among these
test positions, the most commonly used is the

Accepted for publication 30 November 2004.

Address correspondence to S. Sharon Wang, PT, PhD, OCS, Texas Woman’s University, School of Physical Therapy,
8194 Walnut Hill Lane, Dallas, TX 75231. E-mail: swang@twu.edu

33
34 Wang et al/Physiotherapy Theory and Practice 22 (2006) 33
42
position advocated by Kendall, McCreary, and
Provance (1993). Using the Kendall et al method,
the serratus anterior muscle is tested with the sub-
ject lying supine with the shoulder positioned at
90 flexion and the elbow fully extended as the
subject protracts the scapula fully and resists a
downward force at the wrist applied by the tester.
Clarkson (2000) also tests the serratus anterior
muscle in this position except that the tester
applies the downward force at the distal humerus
rather than that at the wrist.
Electromyographic (EMG) tests of serratus
anterior function during various activities may
be useful in helping clinicians determine the best
testing position. During strength testing of a spe-
cific muscle, it is difficult to isolate the intended
muscle without recruiting surrounding muscles.
This difficulty arises when testing the strength of
the serratus anterior muscle using the Kendall
et al method. During serratus anterior muscle
strength testing, it is difficult to isolate the serratus
anterior muscle from the pectoralis major muscle.
Several EMG analyses have examined the activity
of the serratus anterior muscle during shoulder
activities (Decker, Hintermeister, Faber, and
Hawkins, 1999; Ekstrom, Donatelli, and
Soderberg, 2003; Hintermeister et al, 1998; Lear
and Gross, 1998; Moseley et al, 1992). Moseley
and colleagues (1992) found that the serratus
anterior muscle was most active during shoulder
elevation and push-ups with a plus. Push-ups with
a plus were performed by having subjects perform
a push-up with full scapular protraction at the top
of a regular push-up in prone. Additionally, the
pectoralis major muscle was not active during
push-ups with a plus (Townsend, Jobe, Pink,
and Perry, 1991). Hintermeister et al (1998) and
Decker et al (1999) obtained similar EMG results
that forward punch motion and push-up with a
plus elicited the greatest peak activity from the
serratus anterior muscle. Ekstrom and colleagues
(2003) also found that the serratus anterior muscle
was activated maximally with exercises requiring
combined shoulder flexion, horizontal flexion
and external rotation, as well as with shoulder
scaption above 120.
Another problem encountered by clinicians
during strength testing of the serratus anterior
muscle is that of reliability. Manual muscle test-
ing is the most common method used by clini-
cians to test muscle strength, but it is based on
the assumption that the tester can objectively
determine the appropriate result. When per-
forming a manual muscle test, the clinician must
assign a muscle grade by rating the amount of
resistance produced by the contracting muscle.
Because of the subjective judgment of the tester
concerning the amount of resistance applied,
reliable muscle grades are difficult to obtain,
especially in the good to normal strength cate-
gories (Trudelle-Jackson et al, 1994). This dif-
ficulty makes manual muscle testing unable to
detect small changes in the good to normal
strength categories (Hayes, Walton, Szomor,
and Murrell, 2002).
The most common technique used to improve
objectivity of muscle testing by researchers is to
quantify muscle strength using a hand-held
dynamometer (HHD). Unlike manual muscle
testing, HHDs do not require subjective inter-
pretation by the tester. The advantage and
reliability of HHDs have been extensively exam-
ined for the past 15 years. Several studies
have shown that hand-held dynamometry has
high reliability and validity in quantifying
shoulder muscle strength in apparently healthy
adults (Andrews, Thomas, and Bohannon,
1996; Bäckman et al, 1995; Bohannon, 1986;
Bohannon and Andrews, 1987; Brinkmann,
1994; Hayes, Walton, Szomor, and Murrell,
2002; Magnusson, Gleim, and Nicholas, 1990;
Wadsworth et al, 1987) as well as in subjects
with pathology (May, Burnham, and Steadward,
1997; Stuberg and Metcalf, 1988).
In recent years when examining the reliability
and validity of a testing measure, researchers
have focused on smallest detectable difference
(SDD). SDD is defined as the smallest statisti-
cally significant change in measurement results
(Fransen, Crosbie, and Edmonds, 2003). When
the change in strength measures is greater
than the value of the SDD, clinicians can confi-
dently attribute the change to true muscle
strength gain, rather than to measurement
error (Fransen, Crosbie, and Edmonds, 2003).
In other words, a low value of SDD indicates
adequate sensitivity to detect the actual change.
To this date, only one reliability study has
explored the use of SDD for shoulder strength
measurements. Van Meeteren and colleagues
(Van Meeteren, Roebroeck, and Stam, 2002)
investigated test
retest reliability in isokinetic
muscle strength measurements of four shoulder
muscle groups: internal rotators, external
 Wang et al/Physiotherapy Theory and Practice 22 (2006) 33
42
rotators, abductors and adductors. They found
good to excellent two-week test
retest reliability
(ICC ¼ .69
.92; Van Meeteren, Roebrock, and
Stam, 2002). Although no standards have yet been
established for SDD interpretation, Van Meeteren
et al concluded that the SDDs between two indi-
vidual isokinetic strength measurements that ran-
ged from 21% to 43% were not small enough to
detect actual changes in muscle strength.
The purposes of this study were 1) to develop
functional muscle strength and endurance tests
for the serratus anterior muscle that are objec-
tive, clinically feasible, user-friendly, and isolate
the serratus anterior muscle from the surround-
ing muscles, and 2) to determine the inter-tester
reliability, test
retest reliability, and SDD for
these serratus anterior muscle strength and
endurance tests.
Methods
EMG observations
EMG was used to find an optimal testing
position to isolate the serratus anterior muscle.
Surface EMG analysis of the serratus anterior
and pectoralis major muscles was conducted
on 3 healthy subjects prior to the reliability
study. A Delsys surface EMG machine (Delsys,
Inc. 650 Beacon Street, Boston, MA 02215,
USA) was used to observe the serratus anterior
and pectoralis major muscle activity to deter-
mine the optimal testing position of the
shoulder. EMG analysis was used to determine
a test position where the serratus anterior muscle
was maximally recruited while the pectoralis
major muscle was minimally recruited. The
EMG unit consisted of an amplifier with a gain
of 1,000 and a bandpass of 20
450 Hz. The
EMG data were sampled at 1,024 Hz. Bipolar
and pre-amplified surface electrodes with a fixed
distance of 1.0 cm were used to record the mus-
cle activity of the serratus anterior and pectoralis
major. The EMG machine was connected to a
laptop computer where the EMG data were
stored for analysis. Delsys EMGWorks soft-
ware, version 2.0# (Delsys, Inc., 650 Beacon
Street, Boston, MA 02215, USA) was used for
signal acquisition and analysis.
Prior to electrode placement, the subject’s
skin was cleaned with 70% isopropyl alcohol.
35
The electrode for the serratus anterior muscle
was applied to the anterior midaxillary region,
over the fifth or sixth rib, anterior to the latissi-
mus dorsi and placed vertically (Hintermeister
et al, 1998; Lear and Gross, 1998). The electrode
placement for the pectoralis major was midway
from the point between the lateral and middle
third of the clavicle, to the inferior portion of
anterior axillary fold (Nieminen, Takala, and
Viikari-Juntura, 1993). The reference electrode
was placed on the spinous process of the seventh
cervical vertebrae. With the subject in a sitting
position, both electrodes were placed as the sub-
ject’s arm was held in 90 of shoulder flexion
(Ekstrom, Donatelli, and Soderberg, 2003; Lear
and Gross, 1998). This was done in order to
minimize potential skin movement during test-
ing. Manual muscle testing followed to confirm
the electrode placement over these two muscles.
During EMG recording, a 5-second maximal
isometric contraction was recorded at different
shoulder positions while the subject was lying
supine and resisting a downward force generated
by the tester. The EMG data of these three
subjects showed a consistent pattern that in the
position of 90 shoulder flexion with 105 hori-
zontal adduction (position 2), the serratus
anterior muscle activity was higher than in 90
shoulder flexion with 90 horizontal adduction
(position 1). Additionally the pectoralis major
muscle activity in position 2 was lower than in
Table 1. Comparison of eletromyographic root-mean-square
(RMS) values of serratus anterior and pectoral major
muscles in 2 different arm positions in 3 subjects.
RMS value
(per second)
Position Position
Muscles Subject 1 2y
Serratus anterior #1 .047 .080
#2 .068 .073
#3 .029 1.65
Pectoral muscles #1 .069 .014
#2 .076 .055
#3 .057 .049

90 shoulder flexion and 90 shoulder horizontal adduction.
y
90 shoulder flexion and 105 shoulder horizontal
adduction.
36 Wang et al/Physiotherapy Theory and Practice 22 (2006) 33
42

position 1. The EMG data were rectified and
root-mean-squares (RMS) were calculated to
compare the difference in muscle activity of the
serratus anterior and pectoralis major muscles
in the 2 positions (see Table 1). Based on these
EMG results, we decided that the serratus
anterior muscle was best tested in supine pos-
ition with shoulder in 90 shoulder flexion with
105 horizontal adduction.
study. Subjects who reported existing shoulder
pain, history of shoulder pathology or systemic
disease were excluded from the study. Prior
to collecting data, the investigators informed
subjects of the nature and risks of the study.
All subjects gave their written consent. The
study was approved by the Institutional Review
Board of Texas Woman’s University.

Subjects
Thirty students, 26 women and 4 men
between the ages of 22 and 40 years (mean
age ¼ 25.5 years) from Texas Woman’s Univer-
sity at Dallas volunteered for the reliability
Apparatus
The investigators designed an apparatus
(Figure 1) consisting of a wooden platform that
fit securely under a standard plinth. From
the platform, a 2.54 cm (100 ) wide  10.16 cm
(400 board extended at a 15 angle from the

Figure 1. Customized apparatus for assessing serratus anterior muscle strength and endurance.
 Wang et al/Physiotherapy Theory and Practice 22 (2006) 33
42
vertical, thus guiding the subject’s arm to a pos-
ition of 90 of shoulder flexion and 105 of
shoulder horizontal adduction during testing.
This arm position was chosen as the optimal test
position for the serratus anterior muscle because
of less contribution from the pectoralis major
muscles based on observation of EMG record-
ings. A Chatillon MSE 1000 HHD (Ametek
Inc., 37 North Valley Road, Paoli, PA 02215,
USA) was anchored to the bottom of the board.
An adjustable chain with a hand strap was
attached to the HHD. For strength testing using
this design, an upward force exerted by the sub-
ject pulling the hand strap along the extension
board was recorded in newtons. A standard
dumbbell set capable of being adjusted within
5.6 newtons of targeted weight was used for
the serratus anterior muscle endurance test.
Procedure
For the reliability study, each subject partici-
pated in two sessions, with a minimum of 7 days
apart. During each session, the muscle strength
test or the Serratus Anterior Punch Test (SAPT)
was conducted prior to the endurance test in
order to prevent fatigue from affecting the
result of the strength test. Both arms were tested,
and the dominant arm was tested first. The
dominant arm was determined by asking the
subject which arm he=she used for writing
and throwing a ball. The subject then was asked
to lie supine with knees extended and the non-
testing upper extremity at rest beside the
subject’s body. The upper extremity being tested
was aligned with the extension board of the
custom-made apparatus so that the shoulder
was positioned in 90 shoulder flexion, 105
shoulder horizontal adduction, elbow at full
extension, and wrist in neutral. The subject
was instructed to avoid grasping the plinth with
the non-testing upper extremity, holding the
breath, or rotating the trunk during testing.
Tests were stopped immediately if any substitu-
tions were observed. In addition, the subject
was instructed to maintain extended lower extre-
mities during the testing.
During the strength testing, the subject was
asked to remove all of the slack out of the chain
and punch superiorly as hard as he=she could
toward the ceiling. The subject was instructed
37
to hold at end-range for 5 seconds. Each subject
performed the test three times with a one-minute
rest period between each trial. Peak muscle force
for each trial was recorded in newtons. The aver-
age of the three trials was used in data analysis.
The endurance test or the Serratus Anterior
Punch Repetition Test (SAPRT) was performed
in a manner similar to the strength test except
that subjects held a dumbbell weight of 15% of
their body weight. Prior to the study, the value
for 15% of body weight was determined by hav-
ing volunteers assume a push-up plus position
with bathroom scales positioned individually
under each hand. This was the end position of
the push-up plus exercise as described in the
Decker et al (1999) and Moseley et al (1992) stu-
dies. We were able to determine how much body
weight was placed through each of the upper
extremities in a gravity-dependent position.
Therefore, 15% of a subject’s body weight could
be translated into a supine position with the
upper extremity working against gravity. Prior
to the endurance test, all subjects were weighed
on the same standard bathroom scale with shoes
off to determine their dumbbell weights. During
the serratus anterior muscle endurance testing,
subjects were asked to perform full range of
SAPT for as many repetitions as they could until
fatigued, as evidenced by a change in form or
inability to complete full range of motion. The
total number of repetitions performed with good
form was recorded. A higher number of repeti-
tions meant better muscle endurance.
Each of two testers performed the same pro-
cedures separately in each session. The order
of testers was assigned by asking the subject to
randomly draw a number of 1 or 2 from a bowl.
The drawn number indicated which tester would
test first. Subjects were given a minimum of 10-
minute rest between the testers. All subjects were
asked to return 7 days later to repeat the pro-
cedure. Subjects were advised not to perform
any upper extremity workouts during this
period.
Statistical method
Means and standard deviations (SD) were
calculated for the strength and endurance tests
from both testers and from both dominant and
non-dominant arms. The SPSS 10.0# (SPSS
38 Wang et al/Physiotherapy Theory and Practice 22 (2006) 33
42

Inc. Headquarters, 233 S. Wacker Drive, 11th
floor, Chicago, IL 60606, USA) was used to
analyze the data. Both inter-tester and one-week
test
retest reliabilities were assessed using intra-
class correlation coefficients (ICC) with 95%
confidence interval (CI). Standard error of the
measurement (SEM) were calculated to estimate
the SDDs using corresponding reliability values
(Fransen, Crosbie, and Edmonds, 2003; Portney
and Watkins, 2000). For clinical relevance,
SDDs were calculated within 68% p CIffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
using
the formula SDD68% (68% CI) ¼ 2  SEM
(Fransen, Crosbie, and Edmonds, 2003). How-
ever, SDDs were also calculated for statistical
significance pusing the formula SDD95% (95%
ffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
CI) ¼ 1.96  2  SEM (Roebroeck, Harlaar,
and Lankhorst, 1993).
Results
Means and standard deviations of the
strength and endurance measurements are
shown in the Table 2. The ICCs with their corre-
sponding 95% CIs for the inter-tester and one-
week test
retest reliability are listed in Tables
3 and 4, respectively. According to Portney
and Watkins (2000), the values of ICC above
.75 indicate good reliability; those below .75
poor to moderate reliability. Thus, our ICCs
revealed good inter-tester reliability for the
strength testing for both the dominant and
non-dominant arms (ICC2,3 ¼ .90
.93). The
results also showed moderate to good inter-
tester reliability for the endurance test for
both the dominant and non-dominant arms
(ICC2,1 ¼ .71
.76). Both Tester #1 and #2
demonstrated good one-week test
retest
reliability for the strength testing (ICC2,3 ¼
.83
.89). However, both testers #1 and #2
demonstrated moderate test
retest reliability
for the endurance test (ICC2,1 ¼ .44
.62).
The random measurement errors, defined as
the SDD, at 68% for clinical relevance and
95% CI for statistical significance are listed in
Tables 3 and 4. The inter-tester SDDs68% for
the strength tests were reasonably small for clini-
cal relevance, ranging from 22.7 to 27.1 newtons
(5.1
6.1 lbs.) between the 2 testers. The
test
retest SDDs68% were also small for clinical
relevance, ranging from 29.3 to 39.2 newtons
(6.6
8.8 lbs.) for the same testers between 2 ses-
sions with one week apart. However, the inter-
tester and test
retest SDDs68% were moderate
for the endurance tests, ranging from 14 to 21
repetitions between the 2 testers, and 17 to 29

Table 2. Means and standard deviations (SD) of serratus anterior (SA) muscle strength and endurance tests.

Mean  SD

Test Session 1 Session 2

SA Strength test (newtons)
Tester #1
Dominant arm 207.4  56.1 195.8  65.0
Non-dominant arm 197.6  57.4 189.0  67.6
Tester #2
Dominant arm 202.9  62.3 190.0  52.5
Non-dominant arm 200.3  65.0 187.8  69.0
Endurance test (repetitions)
Tester #1
Dominant arm 59  32 59  23
Non-dominant arm 51  21 51  17
Tester #2
Dominant arm 55  26 60  21
Non-dominant arm 54  21 57  21
 Table 3. Inter-tester reliability of two sessions for assessing serratus anterior muscle strength and endurance.

Session 1 Session 2

Test ICCy 95% CI SEM SDD95% SDD68% ICCy 95% CI SEM SDD95% SDD68%
Strength test
(newtons)
Dominant arm .90 .79
.95 18.7 51.9 26.5 .91 .81
.96 17.6 48.8 24.9
Non-dominant arm .93 .85
.97 16.2 44.9 22.9 .92 .83
.96 19.3 53.5 27.3
Endurance test
(repetitions)
Dominant arm .75 .54
.87 15 40 21 .76 .55
.88 11 30 15
Non-dominant arm .75 .54
.87 11 29 15 .71 .48
.85 10 28 14
y
Used ICC2,3 for the strength test, ICC2,1 for the endurance test.

Absolute measurement error (95% and 68% confidence level respectively).
ICC: Intraclass Correlation Coefficient; CI: Confidence Interval; SEM: Standard Error of Measurement; SDD: Smallest Detectable Difference.

39
Table 4. One-week test
retest reliability of the same testers for assessing serratus anterior muscle strength and endurance.

Tester #1 Tester #2

Test ICCy 95% CI SEM SDD95% SDD68% ICCy 95% CI SEM SDD95% SDD68%
Strength test
(newtons)
Dominant arm .85 .69
.93 23.4 64.9 33.1 .87 .74
.94 20.9 57.3 29.3
Non-dominant arm .89 .76
.95 20.7 57.5 29.3 .83 .89
.91 27.6 76.5 39.0
Endurance test
(repetitions)
Dominant arm .44 .10
.69 21 57 29 .59 .29
.78 15 42 21
Non-dominant arm .62 .35
.80 12 32 16 .55 .25
.76 14 39 20
y
Used ICC2,3 for the strength test, ICC2,1 for the endurance test.

Absolute measurement error (95% and 68% confidence level respectively).
ICC: Intraclass Correlation Coefficient; CI: Confidence Interval; SEM: Standard Error of Measurement; SDD: Smallest Detectable Difference.
40 Wang et al/Physiotherapy Theory and Practice 22 (2006) 33
42
repetitions from the same testers between the 2
sessions.
Discussion
Our EMG results were consistent with
findings of several shoulder EMG studies
(Decker, Hintermeister, Faber, and Hawkins,
1999; Hintermeister et al, 1998). We determined
the optimal testing position for the serratus
anterior strength to be with the shoulder in 90
flexion and 105 horizontal abduction. This
testing position is comparable to the forward
punch used in the Hintermeister et al study
(1998) and dynamic hug exercises in the Decker
et al study (1999). Hintermeister and colleagues
(1998) found that the forward punch was one of
the activities that elicited the greatest average
serratus anterior muscle activity. The forward
punch exercise was performed by having sub-
jects stand with their back to the wall and one
foot in front of the other. The subjects then
grasped elastic cords in each hand with the
elbow flexed to 90 and arm held against the
body. Finally, the subjects flexed the shoulder
to 90. Decker and colleagues (1999) also con-
cluded that the dynamic hug exercise elicited
the highest rates of EMG activity in the serratus
anterior muscle. The dynamic hug exercise was
performed by asking subjects to stand with their
backs toward the wall with their elbows flexed
45 and shoulders abducted 60 and internally
rotated 45. Subjects then horizontally flexed
both shoulders until their hands touched. By
adding a horizontal component to the tra-
ditional serratus anterior muscle strength test,
it seemed to be capable of increasing recruit-
ment of the serratus anterior muscle, while
decreasing recruitment of the pectoralis major
muscle. This is consistent with the 105 horizon-
tal adduction (position 2) used in our study.
High inter-tester and one-week test
retest
reliabilities were confirmed for our strength
testing method using the custom-designed appar-
atus and a mounted HHD. We believe that the
serratus anterior muscle was tested in the optimal
position with less contribution from the pectora-
lis major muscle. In addition, this design for the
strength testing eliminated the subjective compo-
nent of the tester. As previously mentioned, the
traditional strength testing for the serratus
anterior muscle requires the subject to resist a
downward force at the hand that is generated
by the tester while lying in spine. Using this tra-
ditional method with a HHD, Donatelli and his
co-workers have shown poor intra-tester
reliability (ICC ¼ .27; Donatelli et al, 2000). In
the present study, the tester was free from the
responsibility of generating the resistance,
thereby eliminating variance due to tester
strength. Additionally, the tester was able to
observe any substituting movements during the
testing, such as trunk rotation, malalignment of
the testing shoulder or insufficient protraction.
Clinicians need an absolute value to confi-
dently explain that a change in muscle strength
has occurred and the change is not a result of
measurement error. Few studies have reported
SDD for strength testing. For a test to be more
clinically valuable, its SDD has to be small so
the test is sensitive enough to detect the differ-
ence. In the present study, we consider the
SDD values for the serratus anterior strength
test to be small for one-week test
retest mea-
surements. For example, the between-session
difference of 29 newtons in Tester #1’s
non-dominant arm (Table 4) indicates that in
order to conclude that the subjects have reached
a clinically significant strength gain, they need to
have a strength gain of 29 newtons or greater.
The endurance test or SAPRT was developed
based on the concept that high repetition and low
load activities are considered key components
when designing rehabilitative exercises for the
serratus anterior muscle. The serratus anterior
muscle is considered a core muscle for the
shoulder indicating that its endurance is essential
during shoulder activity (Paine and Voight,
1993). Defining and measuring muscle endur-
ance has rarely been addressed in the research
literature. Bäckman and colleagues (1995) mea-
sured isometric muscular endurance of shoulder
abductors in normal subjects as the amount of
time the person could sit with the arms abducted
to 90 from the neutral position. However, a
reliable method of quantifying endurance of the
serratus anterior muscle has not been reported.
We believe the number of repetitions that the
subject can complete is a more appropriate indi-
cator of muscular endurance but we also recog-
nize that multiple submaximal repetitions are a
strong predictor of absolute muscle strength
(Dohoney et al, 2002). Lunsford and Perry
 Wang et al/Physiotherapy Theory and Practice 22 (2006) 33
42
(1995), for example, advocate using the number
of repetitions of standing heel-rises to represent
ankle plantarflexor strength.
The ICC values (.71
.76) in our study indi-
cate good inter-tester reliability for the endur-
ance test but moderate one-week test
retest
reliability (ICC ¼ .44
.62). Similar to the results
of the strength test, the inter-tester reliability
was better than the one-week test
retest
reliability. In addition to individual variability,
several possible reasons may contribute to the
inconsistencies. First, the interpretation of fati-
gue may vary with each subject. Secondly, the
repetition method was not paced, using a metro-
nome, for example. As the result, fatigue may
have occurred slower or faster in some subjects.
Lastly, only one measurement was taken for the
endurance testing, resulting lower ICC values
during data analysis. For statistical analysis of
reliability, two or more measurements might
boost the ICCs values.
Conclusion
In summary, the technique and customized
apparatus designed in the present study positioned
the shoulder in the optimal position to test
serratus anterior muscle strength. The results
demonstrated good inter-tester and one-week
test
retest reliability for this technique using
hand-held dynamometry. The minimization of
the tester involvement in the strength test may
account for the result of good reliability. The
SDD for the strength test was small indicating that
the strength testing technique was sensitive
enough to detect clinical changes in serratus
anterior strength. However, we cannot rec-
ommend the endurance test using the repetition
approach used in the present study for clinical
use. For future study, a time trial should be con-
sidered to test serratus anterior muscle endurance.
Also, researchers should examine the reliability of
the strength testing technique used in the present
study on people with shoulder disorders.
References
Andrews AW, Thomas MW, Bohannon RW 1996 Norma-
tive values for isometric muscle force measurements
obtained with hand-held dynamometers. Physical Ther-
apy 76: 248
259
41
Bäckman E, Johansson V, Häger B, Sjöblom P, Henriksson
KG 1995 Isometric muscle strength and muscular endur-
ance in normal persons aged between 17 and 70 years.
Scandinavian Journal of Rehabilitation Medicine 27:
109
117
Bohannon RW 1986 Test
retest reliability of hand-held
dynamometry during a single session of strength assess-
ment. Physical Therapy 66: 206
209
Bohannon RW, Andrews AW 1987 Interrater reliability of
hand-held dynamometry. Physical Therapy 67: 931
933
Brinkmann JR 1994 Comparison of a hand-held and fixed
dynamometer in measuring strength of patients with
neuromuscular disease. Journal of Orthopaedic & Sports
Physical Therapy 19: 100
104
Clarkson HM 2000 Musculoskeletal assessment: joint range
of motion and manual muscle testing, 2nd ed, Philadel-
phia, Lippincott Williams & Wilkins
Decker MJ, Hintermeister RA, Faber KJ, Hawkins RJ 1999
Serratus anterior muscle activity during selected rehabili-
tation exercises. American Journal of Sports Medicine 27:
784
791
Dohoney P, Chromiak JA, Lemire D, Abadie BR, Kovacs C
2002 Prediction of one repetition maximum (1-RM)
strength from a 4
6 RM and a 7
10 RM submaximal
strength test in healthy young adult males. Journal of
Exercise Physiologyonline 5: 54
59.
Donatelli RA, Ellenbecker TS, Ekedahl SR, Wilkes JS,
Kocher K, Adam J 2000 Assessment of shoulder strength
in professional baseball pitchers. Journal of Orthopaedic
& Sports Physical Therapy 30: 544
551
Ekstrom RA, Donatelli RA, Soderberg GL 2003 Surface
electromyographic analysis of exercises for the trapezius
and serratus anterior muscles. Journal of Orthopaedic
& Sports Physical Therapy 33: 247
258
Fransen M, Crosbie J, Edmonds J 2003 Isometric muscle force
measurements for clinicians treating patients with osteoar-
thritis of the knee. Arthritis & Rheumatism 49: 29
35
Hayes K, Walton JR, Szomor ZL, Murrell GAC 2002
Reliability of 3 methods for assessing shoulder strength.
Journal of Shoulder and Elbow Surgery 11: 33
39
Hintermeister RA, Lange GW, Schultheis JM, Bey MJ,
Hawkins RJ 1998 Electromyographic activity and
applied load during shoulder rehabilitation exercises
using elastic resistance. American Journal of Sports
Medicine 26: 210
220
Hislop HJ, Montgomery J 1995 Daniels and Worthingham’s
muscle testing: techniques of manual examination, 6th ed,
Philadelphia, W. B. Saunders
Kendall FP, McCreary EK, Provance PG 1993 Muscles: test-
ing and function, 4th ed, Baltimore, Williams & Wilkins
Kuhn JE, Plancher KD, Hawkins RJ 1995 Scapular winging.
Journal of American Academy of Orthopaedic Surgery 3:
319
325
Lear LJ, Gross MT 1998 An electromyographical analysis of
the scapular stabilizing synergists during a push-up
progression. Journal of Orthopaedic & Sports Physical
Therapy 28: 146
157
42 Wang et al/Physiotherapy Theory and Practice 22 (2006) 33
42
Lunsford BR, Perry J 1995 The standing heel-rise test for
ankle plantar flexion: criterion for normal. Physical Ther-
apy 75: 694
698
Magnusson SP, Gleim GW, Nicholas JA 1990 Subject varia-
bility of shoulder abduction strength testing. American
Journal of Sports Medicine 18: 349
353
May LA, Burnham RS, Steadward RD 1997 Assessment of
isokinetic and hand-held dynamometer measures of
shoulder rotator strength among individuals with spinal
cord injury. Archives of Physical Medicine and Rehabili-
tation 78: 251
255
Moseley JB, Jobe FW, Pink M, Perry J, Tibone J 1992 EMG
analysis of the scapular muscles during a shoulder
rehabilitation program. American Journal of Sports
Medicine 20: 128
134
Nieminen H, Takala EP, Viikari-Juntura E 1993 Normali-
zation of electromyogram in the neck-shoulder region.
European Journal of Applied Physiology 67: 199
207
Paine RM, Voight M 1993 The role of scapula. Journal of
Orthopaedic & Sports Physical Therapy 18: 386
391
Portney LG, Watkins MP 2000 Foundations of clinical
research: application to practice, 2nd ed, Upper Saddle
River, Prentice Hall Health
Roebroeck ME, Harlaar J, Lankhorst GJ 1993 The appli-
cation of gerneralizability theory to reliability assessment:
an illustration using isometric force measurements. Physi-
cal Therapy 73: 386
395
Stuberg WA, Metcalf WK 1998 Reliability of quantitative
muscle testing in healthy children and in children with
Duchenne muscular dystrophy using a hand-held dyna-
mometer. Physical Therapy 68: 977
982
Townsend H, Jobe FW, Pink M, Perry J 1991 Electromyo-
graphic analysis of the glenohumeral muscles during a
baseball rehabilitation program. American Journal of
Sports Medicine 19: 264
272
Trudelle-Jackson E, Jackson AW, Frankowski CM, Long
KM, Meske NB 1994 Interdevice reliability and validity
assessment of the Nichols hand-held dynamometer. Jour-
nal of Orthopaedic & Sports Physical Therapy 20:
302
306
Van Meeteren J, Roebroeck ME, Stam HJ 2002 Test
retest
reliability in isokinetic muscle strength measurements of
the shoulder. Journal of Rehabilitation Medicine 34:
91
95
Wadsworth CT, Krishnan R, Sear M, Harrold J, Nielsen DH
1987 Intrarater reliability of manual muscle testing and
hand-held dynamometer muscle testing. Physical Ther-
apy 67: 1342
1347
Warner JJP, Navarro RA 1998 Serratus anterior dysfunc-
tion: recognition and treatment. Clinical Orthopaedics
and Related Research 349: 139
148
Wiater JM, Flatow EL 1999 Long thoracic nerve
injury. Clinical Orthopaedics and Related Research 368:
17
27