Document Type : Review Article


1 PhD candidate, Department of Health and Sport Medicine, Faculty of Physical Education and Sport Sciences, University of Tehran, Tehran, Iran

2 Department of Health and Sport Medicine, Faculty of Physical Education and Sport Sciences, University of Tehran, Tehran, Iran

3 Faculty of Physical Education and Sport Sciences, University of Allameh Tabataba'i, Tehran, Iran


The use of push-ups has been suggested to strengthen the scapular stabilizers, while incorporating unstable surfaces is recommended to enhance the involvement of the neuromuscular system. However, the impact of this instability on electromyography (EMG) activity in the periscapular muscles during push-ups in individuals with Scapular dyskinesis remains uncertain. Consequently, the objective of the current study was to assess the influence of unstable surfaces on EMG activity in the trapezius and Serratus anterior muscles among individuals with scapular dyskinesis during push-ups.
A comprehensive search was conducted in Web of Science, PubMed, and Scopus databases, covering articles published from the inception of these databases until September 25, 2021. The search strategy utilized three main keyword categories: Scapular dyskinesis, electromyography, and push-up. Initially, 5,249 articles were identified through this search process. After a thorough assessment of the full text of these articles, four studies were deemed suitable for inclusion in the final review. Data extraction and evaluation of methodological quality were carried out as part of the review process. The Standardized Mean Difference (SMD) and corresponding 95% Confidence Interval (CI) were calculated to perform the meta-analysis using Comprehensive Meta-Analysis (CMA) Software, Version 3. Statistical significance was determined by a p-value less than 0.05.
The findings of the study revealed that the utilization of unstable surfaces among individuals with scapular dyskinesis led to an increase in the activity of the upper trapezius (P= 0.011; SMD= 0.807 [95%CI 0.188, 1.427]). Conversely, it reduced the Serratus anterior's activity (P= 0.000; SMD= -0.665 [95%CI -1.023, -0.307]). However, the electromyography activity of the Lower trapezius was not significantly affected (P= 0.176).
Due to the imbalance between the upper trapezius and serratus anterior muscles in individuals with scapular dyskinesis, caution should be exercised when using unstable surfaces. Incorrect utilization of unstable surfaces may worsen these individuals' muscle imbalance. Therefore, it is advisable to approach unstable surfaces with heightened caution in individuals with scapular dyskinesis.


  1. Huang T-S, Ou H-L, Huang C-Y, Lin J-JJJos, surgery e. Specific kinematics and associated muscle activation in individuals with scapular dyskinesis. 2015;24(8):1227-34.
  2. Burn MB, McCulloch PC, Lintner DM, Liberman SR, Harris JDJOjosm. Prevalence of scapular dyskinesis in overhead and nonoverhead athletes: a systematic review. 2016;4(2):2325967115627608.
  3. Pirauá ALT, Pitangui ACR, Silva JP, dos Passos MHP, de Oliveira VMA, Batista LdSP, et al. Electromyographic analysis of the serratus anterior and trapezius muscles during push-ups on stable and unstable bases in subjects with scapular dyskinesis. 2014;24(5):675-81.
  4. Andrade R, Araújo R, Tucci H, Martins J, Oliveira AJSmj. Coactivation of the shoulder and arm muscles during closed kinetic chain exercises on an unstable surface. 2011;52(1):35.
  5. de Araújo RC, de Andrade R, Tucci HT, Martins J, de Oliveira ASJJoab. Shoulder muscular activity during isometric three-point kneeling exercise on stable and unstable surfaces. 2011;27(3):192-6.
  6. Park S-y, Yoo W-gJJoE, Kinesiology. Differential activation of parts of the serratus anterior muscle during push-up variations on stable and unstable bases of support. 2011;21(5):861-7.
  7. Sandhu JS, Mahajan S, Shenoy SJIjoss. An electromyographic analysis of shoulder muscle activation during push-up variations on stable and labile surfaces. 2008;2(2):30.
  8. Torres RJ, Pirauá AL, Nascimento VY, Dos Santos PS, Beltrão NB, de Oliveira VM, et al. Shoulder muscle activation levels during the push-up-plus exercise on stable and unstable surfaces. 2017;26(4):281-6.
  9. Park K-M, Cynn H-S, Kwon O-Y, Yi C-H, Yoon T-L, Lee J-HJTJoS, et al. Comparison of pectoralis major and serratus anterior muscle activities during different push-up plus exercises in subjects with and without scapular winging. 2014;28(9):2546-51.
  10. Belle R, Hawkins RJSotSSL, Mosby Year Book. Dynamic electromyographic analysis of the shoulder muscles during rotational and scapular strengthening exercises. 1990:32-5.
  11. Lear LJ, Gross MTJJoO, Therapy SP. An electromyographical analysis of the scapular stabilizing synergists during a push-up progression. 1998;28(3):146-57.
  12. Moseley JR JB, Jobe FW, Pink M, Perry J, Tibone JJTAjosm. EMG analysis of the scapular muscles during a shoulder rehabilitation program. 1992;20(2):128-34.
  13. Kang F-J, Ou H-L, Lin K-Y, Lin J-JJJoat. Serratus anterior and upper trapezius electromyographic analysis of the push-up plus exercise: a systematic review and meta-analysis. 2019;54(11):1156-64.
  14. de Araújo RC, da Silva HA, Dos Passos MHP, de Oliveira VMA, Pitangui ACRJJoB, Therapies M. Use of unstable exercises in periscapular muscle activity: A systematic review and meta-analysis of electromyographic studies. 2021;26:318-28.
  15. Kibler WB, Sciascia AJBjosm. Current concepts: scapular dyskinesis. 2010;44(5):300-5.
  16. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. 2009;62(10):e1-e34.
  17. Eriksen MB, Frandsen TFJJotMLAJ. The impact of patient, intervention, comparison, outcome (PICO) as a search strategy tool on literature search quality: a systematic review. 2018;106(4):420.
  18. Siegfried N, Muller M, Deeks J, Volmink J, Egger M, Low N, et al. HIV and male circumcision—a systematic review with assessment of the quality of studies. 2005;5(3):165-73.
  19. Kinsella R, Pizzari TJS, elbow. Electromyographic activity of the shoulder muscles during rehabilitation exercises in subjects with and without subacromial pain syndrome: a systematic review. 2017;9(2):112-26.
  20. Hootman JM, Driban JB, Sitler MR, Harris KP, Cattano NMJRsm. Reliability and validity of three quality rating instruments for systematic reviews of observational studies. 2011;2(2):110-8.
  21. Edwards PK, Ebert JR, Littlewood C, Ackland T, Wang AJjoo, therapy sp. A systematic review of electromyography studies in normal shoulders to inform postoperative rehabilitation following rotator cuff repair. 2017;47(12):931-44.
  22. Ganderton C, Pizzari TJS, Elbow. A systematic literature review of the resistance exercises that promote maximal muscle activity of the rotator cuff in normal shoulders. 2013;5(2):120-35.
  23. Karabay D, Emük Y, Kaya DÖJJoSR. Muscle activity ratios of scapular stabilizers during closed kinetic chain exercises in healthy shoulders: a systematic review. 2019;29(7):1001-18.
  24. Schory A, Bidinger E, Wolf J, Murray LJIjospt. A systematic review of the exercises that produce optimal muscle ratios of the scapular stabilizers in normal shoulders. 2016;11(3):321.
  25. Borenstein M, Hedges LV, Higgins JP, Rothstein HR. Introduction to meta-analysis: John Wiley & Sons; 2021.
  26. Cochran WGJB. The combination of estimates from different experiments. 1954;10(1):101-29.
  27. Deeks JJ, Higgins JP, Altman DG, interventions CSMGJChfsro. Analysing data and undertaking meta‐analyses. 2019:241-84.
  28. Egger M, Smith GD, Schneider M, Minder CJB. Bias in meta-analysis detected by a simple, graphical test. 1997;315(7109):629-34.
  29. Egger M, Smith GD, Altman D. Systematic reviews in health care: meta-analysis in context: John Wiley & Sons; 2008.
  30. de Araújo RC, Pirauá ALT, Beltrão NB, Pitangui ACRJJoss. Activity of periscapular muscles and its correlation with external oblique during push-up: Does scapular dyskinesis change the electromyographic response? 2018;36(5):571-7.
  31. De Faria WM, De Oliveira AS, De Freire Sousa DS, Behm D, Pitangui ACR, De Araújo RCJI, et al. Periscapular activity in subjects with scapular dyskinesis during push-ups on stable and unstable support surfaces. 2021;29(1):21-9.
  32. Lee D-h, Cynn H-s, Yoon T-l, Lee J-hJPTK. Does the Use of Sling Influence Scapular Stabilizers’ Activity During Push Up Plus Exercises in Subjects With Scapular Dyskinesis? 2017;24(1):86-96.
  33. Borreani S, Calatayud J, Colado JC, Moya-Nájera D, Triplett NT, Martin FJJoES, et al. Muscle activation during push-ups performed under stable and unstable conditions. 2015;13(2):94-8.
  34. McQuade KJ, Borstad J, de Oliveira ASJPt. Critical and theoretical perspective on scapular stabilization: what does it really mean, and are we on the right track? 2016;96(8):1162-9.
  35. Ludewig PM, Cook TM, Nawoczenski DAJJoO, Therapy SP. Three-dimensional scapular orientation and muscle activity at selected positions of humeral elevation. 1996;24(2):57-65.
  36. Horsak B, Kiener M, Pötzelsberger A, Siragy TJPTiS. Serratus anterior and trapezius muscle activity during knee push-up plus and knee-plus exercises performed on a stable, an unstable surface and during sling-suspension. 2017;23:86-92.
  37. Calatayud J, Borreani S, Colado JC, Martin F, Rogers MEJTP, Sportsmedicine. Muscle activity levels in upper-body push exercises with different loads and stability conditions. 2014;42(4):106-19.
  38. De Mey K, Danneels L, Cagnie B, Borms D, T'Jonck Z, Van Damme E, et al. Shoulder muscle activation levels during four closed kinetic chain exercises with and without Redcord slings. 2014;28(6):1626-35.
  39. Maenhout A, Van Praet K, Pizzi L, Van Herzeele M, Cools AJBJoSM. Electromyographic analysis of knee push up plus variations: what is the influence of the kinetic chain on scapular muscle activity? 2010;44(14):1010-5.
  40. Inman VT, Abbott LCJCO, Research R. Observations of the Function of the Shoulder Joint. 1996;330:3-12.
  41. Willmore EG, Smith MJJS, Elbow. Scapular dyskinesia: evolution towards a systems-based approach. 2016;8(1):61-70.
  42. Uhl TL, Kibler WB, Gecewich B, Tripp BLJAtjoa, surgery r. Evaluation of clinical assessment methods for scapular dyskinesis. 2009;25(11):1240-8.
  43. Ludewig PM, Kamonseki DH, Staker JL, Lawrence RL, Camargo PR, Braman JPJIJoSPT. Changing our diagnostic paradigm: movement system diagnostic classification. 2017;12(6):884.
  44. Struyf F, Geeraerts J, Noten S, Meeus M, Nijs JJPp. A multivariable prediction model for the chronification of non-traumatic shoulder pain: a systematic review. 2016;19(2):1-10.
  45. Kuijpers T, van der Windt DA, van der Heijden GJ, Bouter LMJP. Systematic review of prognostic cohort studies on shoulder disorders. 2004;109(3):420-31.