Clinical Anatomy 14:237–241 (2001)

ORIGINAL COMMUNICATIONS

Serratus Posterior Muscles: Anatomy, Clinical

Relevance, and Function
JOEL A. VILENSKY,1* MARSHA BALTES,1 LAURA WEIKEL,1 JOSEPH D. FORTIN,2
3
AND LOUIS J. FOURIE
1
Department of Anatomy, Indiana University School of Medicine, Fort Wayne, Indiana
2
Spine Technology and Rehabilitation, Fort Wayne, Indiana
3
Empangeni, South Africa

The serratus posterior superior and inferior muscles are generally considered clinically
insignificant muscles that, based on attachments, probably function in respiration. Interest-
ingly, however, there is no evidence supporting a respiratory role for these muscles. In fact,
some electromyographic data refute a respiratory function for these muscles. We suggest that
the serratus posterior muscles function primarily in proprioception. Further, these muscles,
especially the superior, have been implicated in myofascial pain syndromes and therefore
may have greater clinical relevance than commonly attributed to them. Clin. Anat. 14:
237–241, 2001. © 2001 Wiley-Liss, Inc.

Key words: scapulocostal syndrome; myofascial pain syndromes; shoulder pain;

enthesopathy

INTRODUCTION important clinically than commonly realized, and

Two of the most authoritative texts on human anat-
omy are the British and American editions of Gray’s
Anatomy (Clemente, 1985; Williams, 1995). One
would presume that on the functions of human mus-
cles the two texts would be in agreement. We were
thus intrigued by the fact that the British version
indicated that the role of the serratus posterior supe-
rior (SPS) was “uncertain” in man (it is the only
muscle for which this text states this to be the case),
whereas the American edition describes a specific
function for this muscle, namely, elevating the ribs
during deep inspiration. Similarly, for the presumably
related muscle, serratus posterior inferior (SPI), the
British version indicates that the muscle’s action is to
draw the lower ribs downward and backward, “al-
though possibly not in respiration.” In contrast, the
American version of this text states that the muscle is
active during forced expiration.
Considering the conflicting nature of these views,
we undertook a brief review of the anatomy, clinical
relevance, and possible functions of these two mus-
cles, which generally receive only the most cursory
attention in gross anatomy courses. Our review re-
vealed that, at least, the SPS may be much more
therefore should probably receive greater attention in
these courses. Further, we suggest that these muscles
may be primarily proprioceptive in function.
ANATOMY
SPS
Origin. Most current anatomy texts describe this
muscle as arising from the spinous processes of C7-
T2/T3 (Clemente, 1985; Rosse and Gaddum-Rosse,
1997; Williams, 1995). Satoh (1969), based on his dis-
sections and prior work, described the muscle as orig-
inating as high as C3 but no lower than T2. Cunning-
ham’s Textbook of Anatomy (Romanes, 1981) lists the
inferior limit as T4. One of us (LJF), in an unpub-
lished study on ten human cadavers, found that the
typical origin ranged from C6 to T2, although in one
Grant sponsor: This work was partially supported by the Summer
Research Program for Medical Students at the Indiana University
School of Medicine, Fort Wayne Center.
*Correspondence to: Joel A. Vilensky, Ph.D., Indiana University
School of Medicine, 2101 Coliseum Blvd. E., Fort Wayne, IN
46805. E-mail: vilensk@ipfw.edu
Received 8 May 2000; Revised 29 August 2000

© 2001 Wiley-Liss, Inc.

238 Vilensky et al.
Fig. 1. Schematic drawing of the common (dark) and more
extensive but less common (light and dark) attachments of the serratus
posterior superior (upper fibers) and inferior (lower fibers) muscles.
case a thin aponeurosis extended to the spinous pro-
cess of T12.
Insertion. From its origin, the muscle inserts in a
series of digitations into the upper borders of the
upper ribs, just lateral to their angles. It is described as
inserting into ribs 2–5 in all of the basic anatomy texts
and this was also found to be the case in the unpub-
lished study. Satoh (1969) also agrees that this is the
most common span, although it ranged as low as the
seventh rib (Fig. 1).
Innervation. The major textbooks indicate that
the muscle receives its innervation from intercostal
nerves, either T2-T5, T1–T4, or T2–T4. In contrast,
Satoh (1969) lists the typical innervation as C8 –T1/2,
ranging from C7 to T6.
SPI
Origin. Both editions of Gray’s Anatomy (Clem-
ente, 1985; Williams, 1995) consider the muscle to
originate from the spinous process of T11–L2/3. Cun-
ningham’s textbook (Romanes, 1981) simply consid-
ers the origin as the thoracolumbar fascia. Satoh (1970)
indicates that the muscle’s most superior origin is
typically the spinous process of T11, with a range of
T10 to L2. Satoh does not describe the inferior range
of attachments because the muscle blends with the
thoracolumbar fascia.
Insertion. All major sources consider the muscle’s
insertion to be the inferior 3– 4 ribs, again just lateral
to their angles (Fig. 1).
Innervation. Both editions of Gray’s Anatomy con-
sider the SPI to be innervated by intercostal nerves
9 –12, whereas Cunningham’s textbook (Romanes,
1981) and Satoh (1970) indicate intercostal nerves
9 –11.
CLINICAL RELEVANCE
Both SPS and SPI have been implicated in chronic
pain syndromes. Travell et al. (1942) described a con-
dition, “idiopathic myalgia” or “painful shoulder syn-
drome,” in which shoulder pain was hypothesized to
be due to tender areas within muscles. They found
that “the muscle that most often caused pain in the
shoulder region and arm was the serratus posterior
superior.” The pain could often be permanently re-
lieved by injection of procaine hydrochloride directly
into the muscle. The importance of SPS in generating
shoulder pain has been reiterated in both editions of
Travell and Simons’ textbook, Myofascial Pain and
Dysfunction: The Trigger Point Manual (first published as
Travell and Simons, 1983; and later as Simons et al.,
1999). The authors state that referred pain from “trig-
ger points” in this muscle primarily produce pain
under the superior part of the scapula, with extension
to the posterior aspect of the shoulder, and medial
aspect of the hand and forearm. Lifting objects with
the outstretched hands or other activities that cause
the scapula to exert pressure on the SPS may increase
pain. The authors describe a variety of trigger-point
release techniques, an injection procedure to relieve
the pain, and “corrective actions” to reduce the move-
ments and postures that cause excessive overload or
stretch of this muscle. Rachlin (1994) also described
myofascial pain and trigger-point therapy for relieving
pain originating in SPS.
Simons et al. (1999; and the 1983 edition of the
book) have a much shorter section devoted to the SPI.
The authors contend that this muscle can cause an
annoying pain overlying the muscle. The pain tends
to occur after acute back strain, which also causes pain
in the surrounding muscles. Similar types of therapy
are described for relieving the pain in this muscle as
suggested for SPS. Rachlin (1994) also described myo-

fascial pain and trigger-point therapy for relieving pain
originating in SPI.
Because both the SPS and SPI are covered by
overlying muscles (trapezius, rhomboids, latissimus
dorsi), it is difficult to state with certainty that the pain
described by both editions of the Travell and Simons
reference books is caused by those muscles and not
the overlying muscles, although the authors describe
examination procedures to identify the trigger points
within the SPS and SPI. Similarly, the described treat-
ments could have effects on surrounding muscles and
structures rather than on SPS and SPI. Interestingly,
however, there is one study that strongly supports the
view that the SPS, at least, can cause chronic pain.
Fourie (1991) conducted an investigation on
“scapulocostal syndrome,” which he considered the
same as the shoulder pain syndrome described by
Travell et al. (1942). Fourie’s 201 patients complained
of pain and tenderness in the scapulocostal region
with a point of maximal tenderness (trigger point)
near the superior angle of the scapula. Fourie agreed
that the pain originated in the SPS and suggested it
may have been caused by a stretching force on SPS
resulting from overload or postural degeneration, an
abnormal scapulocostal articulation, or pressure on
SPS from overload or retaining a posture for too long.
He considered this syndrome to be primarily an en-
thesopathy of the insertion (rib attachment) of the
SPS. Although conservative treatment consisting of
steroid injection and/or physical rehabilitation proved
95.9% effective, eight patients failed to respond. Six
of these patients underwent a serratotomy (a proce-
dure first described in this paper) in which the SPS
was surgically severed at its origin, while carefully
maintaining the attachments of the trapezius and
rhomboids. Excellent results were seen in all six cases
with no apparent complications. The documented re-
lief of pain after serratotomy in these patients is strong
evidence that pain in the region of the scapulocostal
articulation can be due to abnormal stresses placed on
the SPS. There were no reported postsurgical shoul-
der/trunk abnormalities in these patients.
FUNCTION
Within the recent editions of the major anatomy
reference texts, only the American edition of Gray’s
Anatomy (Clemente, 1985) suggests the muscles func-
tion in respiration. Clemente states that SPS raises the
upper ribs during deep inspiration whereas SPI de-
presses the lower ribs during forced expiration. Within
recent editions of textbooks used in gross anatomy
courses, Hollinshead’s (Rosse and Gaddum-Rosse,
1997) states that both muscles are active during inspi-
Serratus Posterior Muscles 239
ration, with SPS raising the upper ribs and SPI pre-
venting the diaphragm from raising the lower ribs.
Moore and Dalley (1999) state that the muscles are
inspiratory and Snell (2000) indicates that the SPS is
active in inspiration and the SPI in expiration. From
an intuitive viewpoint it seems unlikely that the pri-
mary function of these muscles is to act during deep or
forced respiratory movements. The accessory muscles
that are generally thought to act during these exces-
sive movements have other primary functions. Nev-
ertheless, a fundamental question pertaining to these
muscles is whether their main function is related to
the process of respiration.
There is no electromyographic evidence supporting
a role for either the SPS or SPI in respiration. Thus,
the main evidence suggesting such a role is anatomi-
cal, i.e., the position of its attachments.
There is, however, some electromyographic evi-
dence refuting the view that these muscles function
during respiration. Campbell (1958) reported no
marked respiratory activity in SPI (he did not test
SPS), but it is important to report that this work was
done using surface electrodes. Nevertheless, Camp-
bell tried to isolate the activity of underlying muscles
such as the SPI by examining the activity of the
overlying muscles at other sites (where the underlying
muscle was not present) and then comparing the
amount of activity. Thus, we believe Campbell’s find-
ings have some validity. Ogawa et al. (1960) studied
30 so-called accessory respiratory muscles in dogs us-
ing in-dwelling electrodes to determine if during hy-
percapnia, which induced increased respiratory activ-
ity that would presumably be associated with forced
respiration, these muscles showed activity. The dogs
were anaesthetized and placed on their sides for ex-
amination of dorsal muscles, and supine for ventral
and lateral muscles. Both the SPS and SPI showed
insignificant activity. Whereas these results could
have been affected by the position, muscle distortion,
or other factors having to do with the habitus or status
of the anaesthetized animal, they do appear convinc-
ing because consistent activity was recorded for the
dilator naris, intrinsic muscle of the larynx, scalenus
anterior, intercostals, rectus abdominus, external and
internal obliques, and transversus abdominus muscles.
Further, the serratus muscles are more extensive in
dogs than in humans and are considered respiratory
muscles (Evans and Christensen, 1979).
If the serratus posterior muscles do not function in
respiration, and assuming they serve some function,
what might it be? As far as we can determine, there is
only one published statement that specifically at-
tributes a nonrespiratory function to either the SPS or
SPI. Simons et al. (1999; and the earlier edition, Trav-
240 Vilensky et al.
ell and Simons, 1983) suggest that the SPI functions
synergistically with the ipsilateral iliocostalis and lon-
gissimus for rotation (unilateral) and extension (bilat-
eral) of the spine. Pertaining to respiration, the au-
thors suggest the muscle acts synergistically with the
quadratus lumborum.
We suggest that the SPS and SPI may primarily act
as proprioceptors. In humans, the most striking fea-
ture of these muscles is their location at the superior
and inferior ends of the thoracic spine. Because the
thoracic spine is the most stable region of the presacral
vertebral column with vertebral injuries common at
the junction of this region with the more mobile cer-
vical and lumbar vertebrae, one hypothesis is that
these muscles act as stretch receptors sensing the
strain on the spine at these levels. Another hypothesis
is that they sense and signal the movements of the
thoracic cavity that are associated with respiration.
Further, the SPS, being located in the scapulocostal
articulation but not able to affect the movements of
the scapula, may act as a proprioceptor for this joint.
In support of our suggestion that SPS and SPI may
function primarily as proprioceptors, Peck et al. (1984)
hypothesized, based on greater muscle spindle densi-
ties, that small muscles act as kinesiological monitors
for larger muscles crossing the same joint. Although
more recent studies have reported that absolute and
relative number of spindles are correlated with muscle
weight, number of motor units, and joint movement
complexity (Buxton and Peck, 1989), and therefore
not directly with presumed proprioceptive function,
we believe Peck et al.’s hypothesis pertaining to a
primarily proprioceptive role for some muscles is war-
ranted. For example, the contractile power of plantaris
compared to the triceps surae is minuscule, but its
short muscle belly will undergo much greater relative
changes in length than the triceps. These greater
length changes may be important to the CNS relative
to controlling ankle joint movements.
Muscle spindle data from human infants are avail-
able for SPS and SPI (Voss, 1971). SPS has a spindle
density of 14.3 spindles/gram of muscle tissue whereas
SPI has a value of 2.97. Unfortunately, as noted above,
interpreting these numbers is problematic. Thus, such
data, without physiological recordings, do not support
or refute the view that these muscles are primarily
proprioceptive in function.
With specific regard to proprioception in presumed
accessory respiratory muscles, Furusawa et al. (1994)
demonstrated in rats that discharges from the mylo-
hyoid muscle were synchronized with respiration and
that stimulation of the mylohyoid nerve, which inner-
vates the muscle, resulted in contraction of the ster-
nohyoid muscle, which contributes to the mainte-
nance of upper airway patency. They suggested that
this relationship is important during respiration. A
similar relationship may also exist between SPS and
SPI and the major respiratory muscles.
The findings by Fourie (1991) that serratotomy had
no apparent detrimental effects on his patients could
be interpreted to mean that these muscles serve no
useful function in humans. However, because he did
not specifically perform pre- and postoperative tests to
assess shoulder/respiratory/trunk movements or activ-
ities in these patients, this conclusion is unwarranted.
Further, redundancy in the nervous and musculoskel-
etal systems may have masked any deficiencies asso-
ciated with the procedure.
DISCUSSION
There is convincing evidence that both SPS and
SPI can be the source of myofascial pain, which pre-
sumably originates from trigger points within the mus-
cles. Such trigger points are thought to contain mul-
tiple minute loci, perhaps containing sensory
receptors or fibers that are located near dysfunctional
motor endplates (Hong and Simons, 1998). Presum-
ably, these trigger points develop when there is ab-
normal relationships (and thus abnormal stresses) be-
tween the muscles of the surrounding functional unit,
in the case of SPS, the scapulocostal articulation (Ger-
win, 1997; Hong and Simons, 1998). Interestingly,
chronic pain in muscles supplied by intercostal nerves
has been reported by patients after herpes zoster in-
fection of these nerves (Chen et al., 1998). Because
these patients also responded to trigger-point injec-
tions, it is possible that pain originating in SPS and
SPI may result from a prior herpes infection. Lastly,
Satoh’s (1969) finding that SPS is innervated at a
higher segmental level than commonly reported in
textbooks (C8 vs. T1) is consistent with the referred
pain pattern indicated in Simons et al. (1999), i.e.,
extending along medial side of the upper limb from
the posterior aspect of the shoulder to the little finger.
We suggest the SPS and SPI have reflex connec-
tions with the respiratory muscles such that over-
stretching results in compensatory movements.
And/or we believe the muscles may function to mea-
sure stress levels at the superior and inferior limits of
the thoracic spine. Considering, the ambiguous rela-
tionship between muscle spindle density and pre-
sumed proprioceptive function, we suggest better
electromyographic recordings and/or electroneurogra-
phy of the motor and sensory nerves of these muscles,
rather than further histological analysis, would be the
best approach to understanding their function.

In conclusion, we suggest that until there is sup-
portive evidence, no respiratory function be attributed
to either the SPS or the SPI, and that the possible
clinical importance of these muscles as generators of
pain, especially shoulder pain, which is one of the
frequent locations of myofascial pain (Han and Harri-
son, 1997), be mentioned in gross anatomy courses
and textbooks.
ACKNOWLEDGMENT
We thank Mrs. Roberta Shadle for drawing the
illustration.
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