Push Up Plus Exercise

Original Editor - Matt Huey

Top Contributors - Nicole Pinto, Matt Huey, Alexandra Stead, Chelsea Mclene and Kim Jackson  

Introduction

The push up plus is a closed kinetic chain exercise often utilised with people who experience shoulder dysfunction. It is used because it activates the serratus anterior and this may improve scapular kinematics. People with shoulder impingement symptoms have been found to show increased upper trapezius activity, decreased serratus anterior activity and altered scapular motion during arm elevation, greater anterior tilt and internal rotation and reduced upward rotation. Given that the push up plus recruits the serratus anterior strongly relative to the upper trapezius, it is commonly prescribed to address this imbalance.

Anatomical and Biomechanical Rationale

The serratus anterior and upper trapezius act as a force couple: together with the lower trapezius, they rotate the scapula upward, posteriorly tilt it, and externally rotate it during arm elevation, keeping the acromion clear of the humeral head. When the serratus anterior is weak or the upper trapezius becomes overactive, this balance is disrupted. The scapula tends toward increased anterior tipping and internal (medial) rotation, with reduced upward rotation during elevation. Because the serratus anterior also holds the scapula against the thoracic wall, weakness or poor activation can additionally present as scapular winging.

This scapular malposition and altered motion pattern is described clinically as scapular dyskinesis. The 2013 international consensus statement from the "Scapular Summit" concluded that scapular dyskinesis is present in a high proportion of shoulder injuries, that shoulder impingement symptoms in particular are affected by it, and that rehabilitation programmes aimed at restoring scapular position and motion can be effective as part of a broader shoulder rehabilitation programme. The push up plus is one of the primary exercises recommended, since actively protracting the scapula against resistance recruits the serratus anterior more than the upper trapezius, addressing the imbalance directly. EMG studies in healthy participants have reported high serratus anterior activity during the plus phase. Clinical trials of scapular stabilisation exercise more broadly, rather than the push up plus specifically, suggest benefit for subacromial pain. However, the direct effect of the push up plus on pain and winging is less well established than its effect on muscle activity.

Technique

The push up plus is performed from the same start position as a standard push up:

• Hands and toes on the floor
• Hands roughly shoulder-width apart
• Elbows extended
• The body held in a straight line from head to heels

Unlike a standard push up, the participant does not lower the body toward the floor. Instead, from the extended-arm start position, the participant performs an additional "plus" phase:

• Pushing through the hands to actively protract the scapulae
• Rounding the upper back slightly, without allowing the elbows to bend.

This end-range protraction is the phase that most selectively recruits the serratus anterior over the upper trapezius, which is why it is added on top of the standard push up rather than replacing it.

Technique pitfalls

Common technique faults to watch for:

• Elbow flexion during the plus phase: this shifts load back onto the pectoralis major/triceps and reduces serratus anterior demand.
• Trunk sag or lumbar extension: indicates inadequate core/scapular control for the chosen level and signals a need to regress the exercise.
• Asymmetrical protraction: may indicate unilateral serratus anterior weakness or winging and should prompt reassessment.

• 
  Push up plus start position
• 
  Push up plus end position

Variations

The push up plus exercise can be modified or progressed by altering the base of support and body position to change the proportion of body mass borne through the upper extremity, rather than by changing the movement pattern itself.

• Wall: Standing near a wall with the arms extended and leaning forward against the wall. This position places relatively little weight through the upper extremities and is often used as a starting position.
• Table: Assuming an inclined position with the hands placed on a table or other firm surface. This position increases weight bearing through the upper extremities compared with the wall position.
• Quadruped: Supporting the body on the hands and knees with the arms extended. This position provides greater weight bearing through the upper extremities than the wall or table positions.

• Floor (Standard Push-Up Position): Maintaining a standard push-up position with the arms fully extended and the body supported on the hands and toes. This position provides greater weight bearing through the upper extremities.

• Added Resistance: Once the floor position is well tolerated, additional resistance can be introduced by either placing a resistance band around the trunk and securing it from hand to hand or elevating the feet on a stable support. Both methods increase the load placed on the upper extremities.

Conclusion

The push up plus is a well-evidenced closed-kinetic-chain exercise for selectively strengthening the serratus anterior relative to the upper trapezius, addressing the muscular imbalance that underlies scapular dyskinesis in many patients with shoulder pain. Evidence for its direct clinical effect is stronger for muscle activation than for pain or winging outcomes. Its clinical value is best supported for patients with subacromial pain syndrome/impingement symptoms and scapular winging, where restoring serratus anterior activation and scapular upward rotation is a recognised rehabilitation target. Clinicians commonly progress from supported positions (wall, incline, quadruped) toward the floor position, and then to externally loaded variants (resistance band, feet elevated) as control improves. This progression is based on clinical practice rather than trial evidence.