On the Role of the Left Serratus Anterior For Management of a Superior T4 Syndrome

Question: If a patient is looking like a Superior T4 syndrome having more restricted left apical expansion after a Superior T4 manual technique, I would attempt to clear this with right subclavius manual technique and then have them do a left low trap and left serratus anterior program. My question is if anyone can explain why the non-manual techniques for this program in the course manual, namely Supine Weighted Punch with Right Apical Expansion and Seated Resisted Serratus Punch with Left Hamstrings both show the subject doing a RIGHT serratus punch??
(*This question came up on the PRI Google group, and we loved the dialogue and response, so we have posted it here for others to learn from as well.)

This is a common question, and to be fair, it does seem counter-intuitive. Louise Kelley and I, along with Skip George, have had several conversations with Ron about this question, and we hope our explanation is helpful. My apologies that it has taken us a couple of days to get this to you, but we wanted to make sure we answered your questions.
Just so we are all on the same page, a Superior T4 syndrome shows up as a compensatory respiration strategy because the body realizes that there isn’t enough air getting into the body by inflating the L lung alone. The respiratory demand exceeds what can be drawn into the already expanded L lung. As a result, the body attempts to open the R apical region in the interest of seeing if air will find its way into that region, thus assisting with air flow. The problem is that the center of mass remains lateralized to the R, so the elevated R upper rib cage can’t accept air. As long as the COM remains lateralized R, and we don’t have a L ZOA, that open R apical chamber is a non-usable region of respiration. Over time, the overactive accessory muscles become shortened, causing a loss of reciprocal rotation of the upper ribs and alternating apical expansion and compression.
We want the upper four ribs on the R to ER with respiration and a L ZOA. But at this point, they don’t know how to do any of that because the R clavicle and R 1st rib are glued together. The right subclavius becomes very tonic because of the elevated position of the 1st rib to the clavicle. The subclavius inhibition technique is designed to get the clavicle and first rib to separate and allow the top four ribs to move in unison into IR with the lower ribs. Subsequently, we can institute proper breathing mechanics via proper group function rib mechanics on the R and L side.
After the R subclavius release, it’s time to get all the ribs on the R side to ER correctly, and all the ribs on the L side to IR correctly, with the COM shifted to the L. This is why most of the initial non-manual activities in the L low trap/serratus section involve a R arm reach. We need the serratus to ER the rib cage, but the overwhelming big deal is we need the R serratus to push the center of mass to the L.  
Following the R subclavius technique, we begin with a R arm reach because:
We want to promote universal R rib cage ER. Think of the R serratus as like a sideways diaphragm on the lateral rib cage. When it contracts and flattens, it pushes the center of mass to the L side with some R rib cage ER. This is assisted by the R low trap as it rotates the spine below T8 to the L.  
As an aside, just a piece of clinical advice: when you have them reach with their R arm, make sure their hand is above their head. This brings in some R upper trap to help elevate the scapula and clavicle correctly, allowing the upper 4 ribs to properly and freely elevate. Also, if the R scapulae isn’t higher than the L, you aren’t really on your L side.  
This activity of the R serratus puts them into the L side of their body, properly positioning the frontal plane L lower trap and the sagittal plane L serratus to perform L thoracic abduction and L rib retraction to assist in the maintenance of the L ZOA, while the COM is lateralized to the L. The action of the L low tap, L serratus, and R serratus are all concentric in nature.
Upon inhalation, the right ribs will now ER, in unison, to assist with filling of right lung regions – apical and lateral – with air.
In that R arm reach/L ZOA position, every inhale is R upper trunk rotation and L low trap/L serratus activation, which is driven by respiration. The reason that the R arm reach/L ZOA position is R upper trunk rotation during inhalation: in that position, the L ZOA will promote air flow into the R lung. When air arrives into the R lung, the R rib cage must ER. This L rib cage IR and R rib cage ER is R upper trunk rotation from a neuromechanical/respiratory point of view.
As you’ll note, the later exercises in the L low trap/L serratus section will have L arm reaching. This is to engrain the concept of "delay" so the COM stays lateralized to the L a bit longer, and the L arm understands how to reach up and forward without L rib cage ER. We then reverse and reach with the left arm to rotate the spine and rib cage to the right while maintaining a left ZOA and COM to the left.  We cue our patients to expand the left posterior ribs, or move the left ribs back, with each inhale. This is left serratus anterior activity. The left lower trap stabilizes the spine in right trunk rotation and assists with maintaining a left ZOA with L thoracic abduction. Now, the L diaphragm is able to move air into the left posterior lung and right apical lung region during right trunk rotation, without losing left rib IR.
This is what cements the references of the L heel, L anterior hip, L ischial tuberosity, L PME, L ab wall, R scapula/lateral rib cage, and R suboccipital region.  As a result, this is compression of the L side of the body, and decompression of the R side of the body.  
We hope this helps to better understand why the Right arm reach is included in the Left low trap/Left serratus program, and why the Right arm reach precedes the Left.

Dan Houglum, MSPT, ATC/L, PRC and Louise Kelley, DPT, PRC

Further contribution to this discussion by Michael Mullin, PTA, ATC, PRC:

Dan Houglum and Louise Kelley, you are fantastic. This is an incredibly helpful explanation for everyone….

While being hesitant to try and supplement in any way, I might also offer that the manual Sibson’s fascia technique is very helpful and I use it after I perform the subclavius technique. I teach a self manual technique as well. It helps keep that pesky tissue from trying to continue to yank things from both attachments.

From an anatomical perspective, it’s important to remember that the apex of the lungs extend up above the level of the clavicle. It is trying so hard to expand on that right side that it will find any "space" it can find to try and open things up.  And when a system is right anchored, it will stretch out wherever possible to try and breathe.  

The Institute’s algorithm is excellent and Dan and Louise’s explanation should be carefully reviewed–a couple times–so you can fully appreciate what they are saying.

Response by Dan Houglum: 

I appreciate your kind words. We debated about talking about Sibson’s fascia in our email. But since you brought it up…..

While I don’t disagree that the fascia can be a problem, I would be cautious about doing a Sibson’s release on every patient on whom you perform a subclavius release, mainly because not everyone’s Sibson’s fascia requires releasing. I don’t want to put words in your mouth, but I don’t believe you’re saying to automatically do a Sibson’s release on everyone every time. But I just wanted to clarify so there is no misinterpretation.    

If the fascia doesn’t require releasing, and that manual release is performed, you run the risk of inducing neural tension and scalene over-stretching. Remember, we need the scalenes to elevate the ribs properly. We don’t want to over-inhibit them unnecessarily. The Sibson’s release is great after you’ve done some R UE reaching (which quiets the anterolateral neck muscles anyway) and you’re transitioning to L UE reaching, but they just don’t seem to be able to perform R scapular retraction. Or, they perform R shoulder extension instead of R scapular retraction. Or, they just don’t seem to be getting off their R leg because their head is still centered over the R leg. Or, their R HG IR just isn’t cleaning up, but everything else is. I’d also suggest performing Sibson’s release in conjunction with L pec inhibition because tightness in both of those structures will inhibit the rhomboids on the R, causing difficulty in performing R scapular retraction and R upper trunk rotation while staying lateralized to the Left.   

I couldn’t agree more with your email, and particularly your statement that it’s hard to inhale into the R apical lung cupula if there is no room. I only wanted to chime in purely in the interest of clarification. Observing the vascular and neural anatomy related to Sibson’s fascia and the neurological reasons for that fascia becoming tight in the first place are important things to consider before performing a Sibson’s release.