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Physiotherapy Theory and Practice, 22(1):3342, 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 testretest 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 testretest 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 testretest 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,


and Hawkins, 1995; Warner and Navarro, 1998).
Normal function of the serratus anterior Although clinicians understand the impor-
muscle is essential in maintaining proper scapulo- tance of the serratus anterior muscle to normal
humeral rhythm during arm elevation (Decker, shoulder function, assessment of serratus anterior
Hintermeister, Faber, and Hawkins, 1999; muscle strength presents multiple problems. The
Warner and Navarro, 1998; Wiater and Flatow, first problem is the difficulty of determining the
1999). When serratus anterior muscle strength is optimal position to test serratus anterior strength
insufficient, scapular upward rotation and pro- without recruiting other muscles. Several differ-
traction is inadequate, making shoulder impinge- ent test positions are advocated for testing
ment more likely to occur (Kuhn, Plancher, and serratus anterior muscle strength (Clarkson,
Hawkins, 1995; Wiater and Flatow, 1999). In 2000; Hislop and Montgomery, 1995; Kendall,
addition, weakness of the serratus anterior is often McCreary, and Provance, 1993). Among these
associated with scapular winging, which is also 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) 3342

position advocated by Kendall, McCreary, and determine the appropriate result. When per-
Provance (1993). Using the Kendall et al method, forming a manual muscle test, the clinician must
the serratus anterior muscle is tested with the sub- assign a muscle grade by rating the amount of
ject lying supine with the shoulder positioned at resistance produced by the contracting muscle.
90 flexion and the elbow fully extended as the Because of the subjective judgment of the tester
subject protracts the scapula fully and resists a concerning the amount of resistance applied,
downward force at the wrist applied by the tester. reliable muscle grades are difficult to obtain,
Clarkson (2000) also tests the serratus anterior especially in the good to normal strength cate-
muscle in this position except that the tester gories (Trudelle-Jackson et al, 1994). This dif-
applies the downward force at the distal humerus ficulty makes manual muscle testing unable to
rather than that at the wrist. detect small changes in the good to normal
Electromyographic (EMG) tests of serratus strength categories (Hayes, Walton, Szomor,
anterior function during various activities may and Murrell, 2002).
be useful in helping clinicians determine the best The most common technique used to improve
testing position. During strength testing of a spe- objectivity of muscle testing by researchers is to
cific muscle, it is difficult to isolate the intended quantify muscle strength using a hand-held
muscle without recruiting surrounding muscles. dynamometer (HHD). Unlike manual muscle
This difficulty arises when testing the strength of testing, HHDs do not require subjective inter-
the serratus anterior muscle using the Kendall pretation by the tester. The advantage and
et al method. During serratus anterior muscle reliability of HHDs have been extensively exam-
strength testing, it is difficult to isolate the serratus ined for the past 15 years. Several studies
anterior muscle from the pectoralis major muscle. have shown that hand-held dynamometry has
Several EMG analyses have examined the activity high reliability and validity in quantifying
of the serratus anterior muscle during shoulder shoulder muscle strength in apparently healthy
activities (Decker, Hintermeister, Faber, and adults (Andrews, Thomas, and Bohannon,
Hawkins, 1999; Ekstrom, Donatelli, and 1996; Bäckman et al, 1995; Bohannon, 1986;
Soderberg, 2003; Hintermeister et al, 1998; Lear Bohannon and Andrews, 1987; Brinkmann,
and Gross, 1998; Moseley et al, 1992). Moseley 1994; Hayes, Walton, Szomor, and Murrell,
and colleagues (1992) found that the serratus 2002; Magnusson, Gleim, and Nicholas, 1990;
anterior muscle was most active during shoulder Wadsworth et al, 1987) as well as in subjects
elevation and push-ups with a plus. Push-ups with with pathology (May, Burnham, and Steadward,
a plus were performed by having subjects perform 1997; Stuberg and Metcalf, 1988).
a push-up with full scapular protraction at the top In recent years when examining the reliability
of a regular push-up in prone. Additionally, the and validity of a testing measure, researchers
pectoralis major muscle was not active during have focused on smallest detectable difference
push-ups with a plus (Townsend, Jobe, Pink, (SDD). SDD is defined as the smallest statisti-
and Perry, 1991). Hintermeister et al (1998) and cally significant change in measurement results
Decker et al (1999) obtained similar EMG results (Fransen, Crosbie, and Edmonds, 2003). When
that forward punch motion and push-up with a the change in strength measures is greater
plus elicited the greatest peak activity from the than the value of the SDD, clinicians can confi-
serratus anterior muscle. Ekstrom and colleagues dently attribute the change to true muscle
(2003) also found that the serratus anterior muscle strength gain, rather than to measurement
was activated maximally with exercises requiring error (Fransen, Crosbie, and Edmonds, 2003).
combined shoulder flexion, horizontal flexion In other words, a low value of SDD indicates
and external rotation, as well as with shoulder adequate sensitivity to detect the actual change.
scaption above 120. To this date, only one reliability study has
Another problem encountered by clinicians explored the use of SDD for shoulder strength
during strength testing of the serratus anterior measurements. Van Meeteren and colleagues
muscle is that of reliability. Manual muscle test- (Van Meeteren, Roebroeck, and Stam, 2002)
ing is the most common method used by clini- investigated testretest reliability in isokinetic
cians to test muscle strength, but it is based on muscle strength measurements of four shoulder
the assumption that the tester can objectively muscle groups: internal rotators, external
Wang et al/Physiotherapy Theory and Practice 22 (2006) 3342 35

rotators, abductors and adductors. They found The electrode for the serratus anterior muscle
good to excellent two-week testretest reliability was applied to the anterior midaxillary region,
(ICC ¼ .69.92; Van Meeteren, Roebrock, and over the fifth or sixth rib, anterior to the latissi-
Stam, 2002). Although no standards have yet been mus dorsi and placed vertically (Hintermeister
established for SDD interpretation, Van Meeteren et al, 1998; Lear and Gross, 1998). The electrode
et al concluded that the SDDs between two indi- placement for the pectoralis major was midway
vidual isokinetic strength measurements that ran- from the point between the lateral and middle
ged from 21% to 43% were not small enough to third of the clavicle, to the inferior portion of
detect actual changes in muscle strength. anterior axillary fold (Nieminen, Takala, and
The purposes of this study were 1) to develop Viikari-Juntura, 1993). The reference electrode
functional muscle strength and endurance tests was placed on the spinous process of the seventh
for the serratus anterior muscle that are objec- cervical vertebrae. With the subject in a sitting
tive, clinically feasible, user-friendly, and isolate position, both electrodes were placed as the sub-
the serratus anterior muscle from the surround- ject’s arm was held in 90 of shoulder flexion
ing muscles, and 2) to determine the inter-tester (Ekstrom, Donatelli, and Soderberg, 2003; Lear
reliability, testretest reliability, and SDD for and Gross, 1998). This was done in order to
these serratus anterior muscle strength and minimize potential skin movement during test-
endurance tests. 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
Methods shoulder positions while the subject was lying
EMG observations supine and resisting a downward force generated
by the tester. The EMG data of these three
EMG was used to find an optimal testing subjects showed a consistent pattern that in the
position to isolate the serratus anterior muscle. position of 90 shoulder flexion with 105 hori-
Surface EMG analysis of the serratus anterior zontal adduction (position 2), the serratus
and pectoralis major muscles was conducted anterior muscle activity was higher than in 90
on 3 healthy subjects prior to the reliability shoulder flexion with 90 horizontal adduction
study. A Delsys surface EMG machine (Delsys, (position 1). Additionally the pectoralis major
Inc. 650 Beacon Street, Boston, MA 02215, muscle activity in position 2 was lower than in
USA) was used to observe the serratus anterior
and pectoralis major muscle activity to deter-
mine the optimal testing position of the Table 1. Comparison of eletromyographic root-mean-square
shoulder. EMG analysis was used to determine (RMS) values of serratus anterior and pectoral major
a test position where the serratus anterior muscle muscles in 2 different arm positions in 3 subjects.
was maximally recruited while the pectoralis
major muscle was minimally recruited. The RMS value
EMG unit consisted of an amplifier with a gain (per second)
of 1,000 and a bandpass of 20450 Hz. The
EMG data were sampled at 1,024 Hz. Bipolar Position Position
and pre-amplified surface electrodes with a fixed Muscles Subject 1 2y
distance of 1.0 cm were used to record the mus- Serratus anterior #1 .047 .080
cle activity of the serratus anterior and pectoralis #2 .068 .073
major. The EMG machine was connected to a #3 .029 1.65
laptop computer where the EMG data were Pectoral muscles #1 .069 .014
stored for analysis. Delsys EMGWorks soft- #2 .076 .055
ware, version 2.0# (Delsys, Inc., 650 Beacon #3 .057 .049
Street, Boston, MA 02215, USA) was used for
signal acquisition and analysis. 
90 shoulder flexion and 90 shoulder horizontal adduction.
Prior to electrode placement, the subject’s y
90 shoulder flexion and 105 shoulder horizontal
skin was cleaned with 70% isopropyl alcohol. adduction.
36 Wang et al/Physiotherapy Theory and Practice 22 (2006) 3342

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

Apparatus
Subjects
The investigators designed an apparatus
Thirty students, 26 women and 4 men (Figure 1) consisting of a wooden platform that
between the ages of 22 and 40 years (mean fit securely under a standard plinth. From
age ¼ 25.5 years) from Texas Woman’s Univer- the platform, a 2.54 cm (100 ) wide  10.16 cm
sity at Dallas volunteered for the reliability (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) 3342 37

vertical, thus guiding the subject’s arm to a pos- to hold at end-range for 5 seconds. Each subject
ition of 90 of shoulder flexion and 105 of performed the test three times with a one-minute
shoulder horizontal adduction during testing. rest period between each trial. Peak muscle force
This arm position was chosen as the optimal test for each trial was recorded in newtons. The aver-
position for the serratus anterior muscle because age of the three trials was used in data analysis.
of less contribution from the pectoralis major The endurance test or the Serratus Anterior
muscles based on observation of EMG record- Punch Repetition Test (SAPRT) was performed
ings. A Chatillon MSE 1000 HHD (Ametek in a manner similar to the strength test except
Inc., 37 North Valley Road, Paoli, PA 02215, that subjects held a dumbbell weight of 15% of
USA) was anchored to the bottom of the board. their body weight. Prior to the study, the value
An adjustable chain with a hand strap was for 15% of body weight was determined by hav-
attached to the HHD. For strength testing using ing volunteers assume a push-up plus position
this design, an upward force exerted by the sub- with bathroom scales positioned individually
ject pulling the hand strap along the extension under each hand. This was the end position of
board was recorded in newtons. A standard the push-up plus exercise as described in the
dumbbell set capable of being adjusted within Decker et al (1999) and Moseley et al (1992) stu-
5.6 newtons of targeted weight was used for dies. We were able to determine how much body
the serratus anterior muscle endurance test. weight was placed through each of the upper
extremities in a gravity-dependent position.
Therefore, 15% of a subject’s body weight could
Procedure be translated into a supine position with the
upper extremity working against gravity. Prior
For the reliability study, each subject partici- to the endurance test, all subjects were weighed
pated in two sessions, with a minimum of 7 days on the same standard bathroom scale with shoes
apart. During each session, the muscle strength off to determine their dumbbell weights. During
test or the Serratus Anterior Punch Test (SAPT) the serratus anterior muscle endurance testing,
was conducted prior to the endurance test in subjects were asked to perform full range of
order to prevent fatigue from affecting the SAPT for as many repetitions as they could until
result of the strength test. Both arms were tested, fatigued, as evidenced by a change in form or
and the dominant arm was tested first. The inability to complete full range of motion. The
dominant arm was determined by asking the total number of repetitions performed with good
subject which arm he=she used for writing form was recorded. A higher number of repeti-
and throwing a ball. The subject then was asked tions meant better muscle endurance.
to lie supine with knees extended and the non- Each of two testers performed the same pro-
testing upper extremity at rest beside the cedures separately in each session. The order
subject’s body. The upper extremity being tested of testers was assigned by asking the subject to
was aligned with the extension board of the randomly draw a number of 1 or 2 from a bowl.
custom-made apparatus so that the shoulder The drawn number indicated which tester would
was positioned in 90 shoulder flexion, 105 test first. Subjects were given a minimum of 10-
shoulder horizontal adduction, elbow at full minute rest between the testers. All subjects were
extension, and wrist in neutral. The subject asked to return 7 days later to repeat the pro-
was instructed to avoid grasping the plinth with cedure. Subjects were advised not to perform
the non-testing upper extremity, holding the any upper extremity workouts during this
breath, or rotating the trunk during testing. period.
Tests were stopped immediately if any substitu-
tions were observed. In addition, the subject
was instructed to maintain extended lower extre- Statistical method
mities during the testing.
During the strength testing, the subject was Means and standard deviations (SD) were
asked to remove all of the slack out of the chain calculated for the strength and endurance tests
and punch superiorly as hard as he=she could from both testers and from both dominant and
toward the ceiling. The subject was instructed non-dominant arms. The SPSS 10.0# (SPSS
38 Wang et al/Physiotherapy Theory and Practice 22 (2006) 3342

Inc. Headquarters, 233 S. Wacker Drive, 11th .75 indicate good reliability; those below .75
floor, Chicago, IL 60606, USA) was used to poor to moderate reliability. Thus, our ICCs
analyze the data. Both inter-tester and one-week revealed good inter-tester reliability for the
testretest reliabilities were assessed using intra- strength testing for both the dominant and
class correlation coefficients (ICC) with 95% non-dominant arms (ICC2,3 ¼ .90.93). The
confidence interval (CI). Standard error of the results also showed moderate to good inter-
measurement (SEM) were calculated to estimate tester reliability for the endurance test for
the SDDs using corresponding reliability values both the dominant and non-dominant arms
(Fransen, Crosbie, and Edmonds, 2003; Portney (ICC2,1 ¼ .71.76). Both Tester #1 and #2
and Watkins, 2000). For clinical relevance, demonstrated good one-week testretest
SDDs were calculated within 68% p CIffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
using reliability for the strength testing (ICC2,3 ¼
the formula SDD68% (68% CI) ¼ 2  SEM .83.89). However, both testers #1 and #2
(Fransen, Crosbie, and Edmonds, 2003). How- demonstrated moderate testretest reliability
ever, SDDs were also calculated for statistical for the endurance test (ICC2,1 ¼ .44.62).
significance pusing the formula SDD95% (95%
ffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi The random measurement errors, defined as
CI) ¼ 1.96  2  SEM (Roebroeck, Harlaar, the SDD, at 68% for clinical relevance and
and Lankhorst, 1993). 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-
Results cal relevance, ranging from 22.7 to 27.1 newtons
(5.16.1 lbs.) between the 2 testers. The
Means and standard deviations of the testretest SDDs68% were also small for clinical
strength and endurance measurements are relevance, ranging from 29.3 to 39.2 newtons
shown in the Table 2. The ICCs with their corre- (6.68.8 lbs.) for the same testers between 2 ses-
sponding 95% CIs for the inter-tester and one- sions with one week apart. However, the inter-
week testretest reliability are listed in Tables tester and testretest SDDs68% were moderate
3 and 4, respectively. According to Portney for the endurance tests, ranging from 14 to 21
and Watkins (2000), the values of ICC above 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 testretest 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) 3342

repetitions from the same testers between the 2 anterior muscle requires the subject to resist a
sessions. 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
Discussion co-workers have shown poor intra-tester
reliability (ICC ¼ .27; Donatelli et al, 2000). In
Our EMG results were consistent with the present study, the tester was free from the
findings of several shoulder EMG studies responsibility of generating the resistance,
(Decker, Hintermeister, Faber, and Hawkins, thereby eliminating variance due to tester
1999; Hintermeister et al, 1998). We determined strength. Additionally, the tester was able to
the optimal testing position for the serratus observe any substituting movements during the
anterior strength to be with the shoulder in 90 testing, such as trunk rotation, malalignment of
flexion and 105 horizontal abduction. This the testing shoulder or insufficient protraction.
testing position is comparable to the forward Clinicians need an absolute value to confi-
punch used in the Hintermeister et al study dently explain that a change in muscle strength
(1998) and dynamic hug exercises in the Decker has occurred and the change is not a result of
et al study (1999). Hintermeister and colleagues measurement error. Few studies have reported
(1998) found that the forward punch was one of SDD for strength testing. For a test to be more
the activities that elicited the greatest average clinically valuable, its SDD has to be small so
serratus anterior muscle activity. The forward the test is sensitive enough to detect the differ-
punch exercise was performed by having sub- ence. In the present study, we consider the
jects stand with their back to the wall and one SDD values for the serratus anterior strength
foot in front of the other. The subjects then test to be small for one-week testretest mea-
grasped elastic cords in each hand with the surements. For example, the between-session
elbow flexed to 90 and arm held against the difference of 29 newtons in Tester #1’s
body. Finally, the subjects flexed the shoulder non-dominant arm (Table 4) indicates that in
to 90. Decker and colleagues (1999) also con- order to conclude that the subjects have reached
cluded that the dynamic hug exercise elicited a clinically significant strength gain, they need to
the highest rates of EMG activity in the serratus have a strength gain of 29 newtons or greater.
anterior muscle. The dynamic hug exercise was The endurance test or SAPRT was developed
performed by asking subjects to stand with their based on the concept that high repetition and low
backs toward the wall with their elbows flexed load activities are considered key components
45 and shoulders abducted 60 and internally when designing rehabilitative exercises for the
rotated 45. Subjects then horizontally flexed serratus anterior muscle. The serratus anterior
both shoulders until their hands touched. By muscle is considered a core muscle for the
adding a horizontal component to the tra- shoulder indicating that its endurance is essential
ditional serratus anterior muscle strength test, during shoulder activity (Paine and Voight,
it seemed to be capable of increasing recruit- 1993). Defining and measuring muscle endur-
ment of the serratus anterior muscle, while ance has rarely been addressed in the research
decreasing recruitment of the pectoralis major literature. Bäckman and colleagues (1995) mea-
muscle. This is consistent with the 105 horizon- sured isometric muscular endurance of shoulder
tal adduction (position 2) used in our study. abductors in normal subjects as the amount of
High inter-tester and one-week testretest time the person could sit with the arms abducted
reliabilities were confirmed for our strength to 90 from the neutral position. However, a
testing method using the custom-designed appar- reliable method of quantifying endurance of the
atus and a mounted HHD. We believe that the serratus anterior muscle has not been reported.
serratus anterior muscle was tested in the optimal We believe the number of repetitions that the
position with less contribution from the pectora- subject can complete is a more appropriate indi-
lis major muscle. In addition, this design for the cator of muscular endurance but we also recog-
strength testing eliminated the subjective compo- nize that multiple submaximal repetitions are a
nent of the tester. As previously mentioned, the strong predictor of absolute muscle strength
traditional strength testing for the serratus (Dohoney et al, 2002). Lunsford and Perry
Wang et al/Physiotherapy Theory and Practice 22 (2006) 3342 41

(1995), for example, advocate using the number Bäckman E, Johansson V, Häger B, Sjöblom P, Henriksson
of repetitions of standing heel-rises to represent KG 1995 Isometric muscle strength and muscular endur-
ankle plantarflexor strength. ance in normal persons aged between 17 and 70 years.
Scandinavian Journal of Rehabilitation Medicine 27:
The ICC values (.71.76) in our study indi-
109117
cate good inter-tester reliability for the endur- Bohannon RW 1986 Testretest reliability of hand-held
ance test but moderate one-week testretest dynamometry during a single session of strength assess-
reliability (ICC ¼ .44.62). Similar to the results ment. Physical Therapy 66: 206209
of the strength test, the inter-tester reliability Bohannon RW, Andrews AW 1987 Interrater reliability of
was better than the one-week testretest hand-held dynamometry. Physical Therapy 67: 931933
reliability. In addition to individual variability, Brinkmann JR 1994 Comparison of a hand-held and fixed
several possible reasons may contribute to the dynamometer in measuring strength of patients with
inconsistencies. First, the interpretation of fati- neuromuscular disease. Journal of Orthopaedic & Sports
gue may vary with each subject. Secondly, the Physical Therapy 19: 100104
Clarkson HM 2000 Musculoskeletal assessment: joint range
repetition method was not paced, using a metro-
of motion and manual muscle testing, 2nd ed, Philadel-
nome, for example. As the result, fatigue may phia, Lippincott Williams & Wilkins
have occurred slower or faster in some subjects. Decker MJ, Hintermeister RA, Faber KJ, Hawkins RJ 1999
Lastly, only one measurement was taken for the Serratus anterior muscle activity during selected rehabili-
endurance testing, resulting lower ICC values tation exercises. American Journal of Sports Medicine 27:
during data analysis. For statistical analysis of 784791
reliability, two or more measurements might Dohoney P, Chromiak JA, Lemire D, Abadie BR, Kovacs C
boost the ICCs values. 2002 Prediction of one repetition maximum (1-RM)
strength from a 46 RM and a 710 RM submaximal
strength test in healthy young adult males. Journal of
Exercise Physiologyonline 5: 5459.
Conclusion Donatelli RA, Ellenbecker TS, Ekedahl SR, Wilkes JS,
Kocher K, Adam J 2000 Assessment of shoulder strength
In summary, the technique and customized
in professional baseball pitchers. Journal of Orthopaedic
apparatus designed in the present study positioned & Sports Physical Therapy 30: 544551
the shoulder in the optimal position to test Ekstrom RA, Donatelli RA, Soderberg GL 2003 Surface
serratus anterior muscle strength. The results electromyographic analysis of exercises for the trapezius
demonstrated good inter-tester and one-week and serratus anterior muscles. Journal of Orthopaedic
testretest reliability for this technique using & Sports Physical Therapy 33: 247258
hand-held dynamometry. The minimization of Fransen M, Crosbie J, Edmonds J 2003 Isometric muscle force
the tester involvement in the strength test may measurements for clinicians treating patients with osteoar-
account for the result of good reliability. The thritis of the knee. Arthritis & Rheumatism 49: 2935
SDD for the strength test was small indicating that Hayes K, Walton JR, Szomor ZL, Murrell GAC 2002
Reliability of 3 methods for assessing shoulder strength.
the strength testing technique was sensitive
Journal of Shoulder and Elbow Surgery 11: 3339
enough to detect clinical changes in serratus Hintermeister RA, Lange GW, Schultheis JM, Bey MJ,
anterior strength. However, we cannot rec- Hawkins RJ 1998 Electromyographic activity and
ommend the endurance test using the repetition applied load during shoulder rehabilitation exercises
approach used in the present study for clinical using elastic resistance. American Journal of Sports
use. For future study, a time trial should be con- Medicine 26: 210220
sidered to test serratus anterior muscle endurance. Hislop HJ, Montgomery J 1995 Daniels and Worthingham’s
Also, researchers should examine the reliability of muscle testing: techniques of manual examination, 6th ed,
the strength testing technique used in the present Philadelphia, W. B. Saunders
study on people with shoulder disorders. 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.
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