Serratus Posterior Superior Trigger Points

Introduction

The serratus posterior superior is a deep upper back muscle responsible for rib elevation, breathing support, and postural stability. When trigger points develop in this muscle, they can cause upper back pain, rib tightness, and difficulty breathing, often mimicking intercostal neuralgia, thoracic spine dysfunction, or rib joint pain.

Name and Area

  • Name: Serratus Posterior Superior

  • Area: Located in the upper back, running from the spinous processes of C7–T3 to ribs 2–5.

Indications

Serratus posterior superior trigger points may contribute to:

  • Pain in the upper back that feels like a deep, aching sensation (mistaken for trapezius or rhomboid strain)

  • Pain that extends to the ribs and chest (can mimic costochondritis or intercostal neuralgia)

  • Tightness or discomfort that restricts deep breathing (common in those with anxiety or shallow breathing patterns)

  • Pain that worsens with forward shoulder posture or prolonged sitting

  • Pain that increases with deep breaths, coughing, or sneezing

  • Discomfort that feels like "knots" between the shoulder blades

Pain from this muscle is often mistaken for thoracic spine dysfunction, rib joint issues, or lung-related discomfort.

Muscle Action

  • Elevates the Upper Ribs: Assists in deep inhalation and rib movement.

  • Stabilizes the Upper Back: Helps maintain posture and scapular function.

The serratus posterior superior is crucial for breathing mechanics, upper back support, and postural alignment.

Signs and Symptoms

Individuals with serratus posterior superior trigger points often report:

  • Pain along the upper back and between the shoulder blades

  • Pain or tightness in the ribs that feels like a band of tension

  • Discomfort when taking deep breaths, yawning, or coughing

  • Pain that radiates toward the side of the ribcage or chest (can mimic rib dysfunction or cardiac pain)

  • Stiffness or "knots" in the upper back that worsen with poor posture

  • Pain that feels worse after prolonged sitting or desk work

Pain worsens with prolonged slouching, deep breathing, or postural strain.

Schedule Now

Perpetuating Factors

Common causes of serratus posterior superior trigger points include:

  • Forward shoulder posture (common in desk workers, gamers, and cyclists)

  • Shallow breathing or stress-related tension (can cause overuse of the ribcage muscles)

  • Repetitive overhead movements (lifting, throwing, climbing, or swimming)

  • Carrying heavy bags on one shoulder (forces asymmetrical loading on the upper back muscles)

  • Thoracic spine stiffness or rib dysfunction (can cause overuse of the serratus posterior superior for stability)

Trigger Point Referral Pattern

Trigger points in the serratus posterior superior refer pain to:

  • The upper back and between the shoulder blades (Can Mimic Rhomboid or Trapezius Strain)

  • The upper ribs and lateral chest (Mistaken for Costochondritis or Intercostal Neuralgia)

  • The side of the rib cage (Can Resemble Nerve Compression or Lung-Related Pain)

Pain from this muscle is often confused with thoracic outlet syndrome, rib dysfunction, or postural strain.

Differential Diagnosis

Serratus posterior superior trigger points may be mistaken for:

  • Costochondritis (pain and tenderness in the ribs, worsens with deep breathing or pressure on the chest)

  • Intercostal neuralgia (burning, sharp rib pain that worsens with movement or deep breathing)

  • Thoracic spine dysfunction (limited mobility in the upper back, often due to poor posture or injury)

  • Lung conditions (pain that worsens with breathing, coughing, or respiratory issues)

  • Upper trapezius and rhomboid strain (upper back and shoulder pain, common in postural dysfunction and overuse injuries)

A thorough rib, thoracic spine, and breathing assessment is necessary to rule out these conditions.

Associated Trigger Points

Serratus posterior superior trigger points often co-exist with:

  • Rhomboids (upper back and shoulder blade pain, affects postural stability and scapular function)

  • Upper trapezius (neck and shoulder tension, common in forward head posture and chronic stress)

  • Latissimus dorsi (thoracic and shoulder pain, common in overhead movements and heavy lifting)

  • Sternocleidomastoid (SCM) (neck and head pain, can contribute to postural imbalances and tension headaches)

Anatomy and Innervation

Muscle Origin Insertion Innervation
Serratus Posterior Superior Spinous processes of C7–T3 Ribs 2–5 (upper borders) Intercostal nerves (T2–T5)

The serratus posterior superior is innervated by the intercostal nerves (T2–T5), which also control rib movement and breathing mechanics.

Patient Examination

A comprehensive examination should include:

  • Palpation: Identify tender nodules along the upper back, medial scapular border, and ribs.

  • Resisted Shoulder Protraction Testing: Assess pain and weakness when pushing the shoulder blade forward against resistance.

  • Thoracic and Rib Mobility Testing: Check for rib restrictions, thoracic spine stiffness, or pain with deep breathing.

  • Postural and Breathing Assessment: Look for rounded shoulders, forward head posture, or shallow breathing patterns.

Corrective Actions

Dry Needling

  • Dry needling can release trigger points in the serratus posterior superior, reducing rib tightness and improving upper back mobility.

Manual Therapy

  • Trigger Point Release: Apply deep sustained pressure to tight spots along the ribs and scapular region.

  • Myofascial Release: Helps improve circulation and reduce muscle tension in the upper thoracic area.

Stretching

  • Seated Thoracic Extension Stretch: Helps reduce upper back tension and improve rib mobility.

  • Wall Stretch for Rib Expansion: Place the hands on a wall and stretch the arms forward to engage the serratus.

Strengthening Exercises

  • Scapular Stability Exercises (Wall Slides): Helps activate the serratus and improve posture.

  • Deep Breathing Exercises: Encourages proper rib expansion and reduces shallow breathing patterns.

Postural and Movement Adjustments

  • Avoid prolonged slouching (maintain an upright chest position to prevent rib and shoulder strain).

  • Ensure proper breathing mechanics (diaphragmatic breathing can reduce overuse of the serratus posterior superior).

  • Use ergonomic workstation adjustments (prevents forward shoulder posture that can exacerbate upper back tightness).

Conclusion

The serratus posterior superior plays a crucial role in rib elevation, breathing support, and postural control, but trigger points in this muscle can cause significant upper back, rib, and breathing-related pain. By incorporating dry needling, manual therapy, stretching, and postural corrections, individuals can reduce pain, improve mobility, and prevent chronic thoracic dysfunction.

➡️ Learn more about Trigger Points

➡️ Explore our Trigger Point Index

Sources:

  • Travell, J. G., & Simons, D. G. (1983). Myofascial Pain and Dysfunction: The Trigger Point Manual (2nd ed.). Williams & Wilkins.

  • Simons, D., & Travell, J. (1999). The Trigger Point Manual, Volume 2: The Lower Extremities. Williams & Wilkins.

Contact Us to Schedule an Appointment