Punch Out Test for Serratur Anterior

The Serratus Anterior Strength Test, also known as the “push out test”, is used to evaluate weakness of the serratus anterior muscle and to identify scapular winging. This muscle plays a key role in stabilizing the scapula against the thoracic wall during forward elevation of the arm.

Test execution

Patient position

• The patient is standing or seated.

Movement

• The patient is instructed to flex the arm forward to 90°.

Resistance

• The examiner applies a posteriorly directed force against the patient’s arm.

Interpretation

• Positive test: Scapular winging observed along the medial border of the scapula indicates weakness or paralysis of the serratus anterior muscle.

Alternative execution

• The test may also be performed by having the patient do wall push-ups or floor push-ups, which provide a more demanding assessment.

Additional observation

• Patients with serratus anterior weakness may also struggle with abduction or flexion above 90°, although compensation by the lower trapezius may still permit overhead movement¹.

Clinical relevance

• A positive Serratus Anterior Strength Test is strongly suggestive of long thoracic nerve palsy or serratus anterior dysfunction.

• Scapular winging can contribute to impaired shoulder biomechanics, reduced overhead function, and secondary impingement symptoms.

• The test is often combined with observation of wall push-up performance and comparison to the contralateral side.

Conclusion

The Serratus Anterior Strength Test is a simple and effective tool for identifying weakness of the serratus anterior muscle and diagnosing scapular winging. It is especially useful in detecting long thoracic nerve involvement and should be used in combination with functional shoulder assessment.

References

1. David J. Magee. Orthopedic Physical Assessment. 6th edition. Elsevier. 2014.

2. David J. Magee. Orthopedic Physical Assessment. 6th edition. Elsevier. 2014.

3. Scapular Winging - Diagnosis. Dan Blewett. Available from: https://youtu.be/VJzK2wXEaQA

4. The winging scapula and shoulder function explained | Feat. Tim Keeley | No.64 | Physio REHAB. Physio Fitness | Physio REHAB | Tim Keeley. Available from: https://youtu.be/Xp8xx1ruDug

5. JWall Push-up Test for Serratus Anterior, Middle Trapezius, and Lower Trapezius Weakness. COR. Available from: https://youtu.be/4KcHysNGhSg