Push-Up Plus

The Push-Up Plus is a Push-Up variation used to regain appropriate Motor Control and positioning of the Scapula . This variation places greater emphasis on the Serratus Anterior while reducing excessive recruitment of the Upper Trapezius (SOURCE-1). Given the movement pattern and involved Muscle s, the Push-Up Plus may be relevant in the middle-phase of treatment for pathologies such as Scapular Dyskinesis , Glenohumeral Instability and Rotator Cuff Tear / Tendinopathy .

Involved Muscles

• Serratus Anterior - reaches peak activity as the “plus” portion of the movement is performed that approaches 40% of its maximum voluntary contraction. The muscle is almost 10% more active during the concentric portion (SOURCE-3). Recored activity of the Middle fibres (80±38% MVIC) and Lower fibres (73±3% MVIC) supported the notion that the Upper fibres are suited for Scapulothoracic Joint - Protraction (SOURCE-4)

• Rotator Cuff

  • Subscapularis - the Upper portion is almost 3 times more activity at 122±22% of itsMaximal Voluntary Isometric Contraction (MVIC)(SOURCE-2)

  • Supraspinatus - (99±36% MVIC) (SOURCE-2)

  • Infraspinatus - (104±54% MVIC) (SOURCE-2)

• Pectoralis Major - (94±27% MVIC) (SOURCE-2)

• Anterior Deltoid

• Triceps Brachii

• Teres Major - (47±26% MVIC) (SOURCE-2)

• Latissimus Dorsi - (49±25% MVIC) (SOURCE-2)

• Upper and Lower Trapezius - active during the Push-Up portion (SOURCE-6)

• Core

• Erector Spinae

• Gluteus Maximus

• Quadriceps

Procedure

Starting Position:

• Patient is in a Push-Up position, lying prone with hands placed on the ground roughly either side of the Chest

The Push-Up Plus is initiated like the standard Push-Up, straightening both arms and consequently pushing the body away from the ground. The “Plus” portion occurs at the top of the movement where maximal Scapulothoracic Joint - Protraction is added. The movement is then reversed to return to the starting position.

Variation

Commonly used progressions for the Push-Up Plus are:

• Wall Push-Up Plus- the same technique can be performed with The Hands against a wall to diminish the effect of gravity (SOURCE-5)

• Knee Push-Up Plus- boats similar EMG amplitudes despite requiring less load, making it a good regression (SOURCE-3)

• Unstable Base - there is some evidence to indicate a Push-Up Plus performed on an unstable surface increases activity of the lower Serratus Anterior , particularly in the eccentric portion of the movement and may be of greater value for Scapula stabilisation (SOURCE-1).

• Added Resistance

Cluster

Regression

The following exercises can be used as a regression if Push-Up Plus exceed the capacity of the patient:

• Cat-Cow - promotes Vertebral Column movement and mild activity of all Trapezius fibres

• Scapular Punches - unilateral isotonic exercise that emphasises Scapulothoracic Joint - Protraction

• Dynamic Hug - rudimentary isotonic exercise that emphasises Scapulothoracic Joint - Protraction

• Banded Horizontal Adduction - low load isotonic horizontal adduction exercise

• Isometric Chest Squeezes - isometric exercise that isolates Chest

• Bottoms-Up Kettlebell Walk - isometric push/ stability exercise with or without perturbation

• Chest Press Machine - rudimentary horizontal push machine

• Pallof Press - low load horizontal push exercise that emphasises anti-rotation of Core

• Push-Up - bodyweight isotonic horizontal push exercise

Progression

The following exercises can be used as a progression to Push-Ups Plus once exercise proficiency is achieved:

• Bench Press - isotonic horizontal push exercise with capacity for high loads

• Incline DB Bench Press - unilaterally loaded Bench variation on variable incline

• Dips - bodyweight isotonic push exercise with large GH Joint - Extension range

• Half DB Bench Press - unilateral isotonic horizontal pressing motion that emphasises the Anterior Sling

• Kneeling Landmine Press - wholebody, explosive vertical pressing exercise with large overhead range

• Medicine Ball Chest Press - plyometric horizontal pressing motion, often sports relevant

References

1. Park, S.-y., & Yoo, W.-g. (2011). Differential activation of parts of the serratus anterior muscle during push-up variations on stable and unstable bases of support. Journal of Electromyography and Kinesiology, 21(5), 861–867. https://doi.org/10.1016/j.jelekin.2011.07.001

2. Escamilla, R. F., Yamashiro, K., Paulos, L., & Andrews, J. R. (2009). Shoulder muscle activity and function in common shoulder rehabilitation exercises. Sports Medicine, 39(8), 663–685.

3. Decker, M. J., Hintermeister, R. A., Faber, K. J., & Hawkins, R. J. (1999). Serratus anterior muscle activity during selected rehabilitation exercises. The American journal of sports medicine, 27(6), 784–791. https://doi.org/10.1177/03635465990270061601

4. Ekstrom, R. A., Bifulco, K. M., Lopau, C. J., Andersen, C. F., & Gough, J. R. (2004). Comparing the function of the upper and lower parts of the serratus anterior muscle using surface electromyography. The Journal of orthopaedic and sports physical therapy, 34(5), 235–243. https://doi.org/10.2519/jospt.2004.34.5.235

5. Park, Kyung-Mi1; Cynn, Heon-Seock1; Kwon, Oh-Yun2; Yi, Chung-Hwi2; Yoon, Tae-Lim1; Lee, Ji-Hyun1. Comparison of Pectoralis Major and Serratus Anterior Muscle Activities During Different Push-Up Plus Exercises in Subjects With and Without Scapular Winging. Journal of Strength and Conditioning Research 28(9):p 2546-2551, September 2014. \| DOI: 10.1519/JSC.0000000000000443

6. Gioftsos, G., Arvanitidis, M., Tsimouris, D., Kanellopoulos, A., Paras, G., Trigkas, P., & Sakellari, V. (2016). EMG activity of the serratus anterior and trapezius muscles during the different phases of the push-up plus exercise on different support surfaces and different hand positions. Journal of Physical Therapy Science, 28(7), 2114–2118. https://doi.org/10.1589/jpts.28.2114