Periscapular Muscles Research Articles

Scapulohumeral kinematics and neuromuscular control during scaption are associated with passive stiffness and strength of periscapular muscles in competitive adolescent swimmers

The passive stiffness and strength of periscapular muscles may affect scapulohumeral control, especially in overhead athletes due to sports-specific training. This study tried to assess the relationship between the passive stiffness and strength of periscapular muscles, scapulohumeral kinematics and neuromuscular control during scaption in swimmers. Ten male adolescent competitive front-crawl swimmers were recruited. The passive stiffness and strength of periscapular muscles were measured in standard postures by a hand-held myotonometer and dynamometer, respectively. Surface electromyography and electromagnetic tracking systems were synchronized to record the muscle activities and scapulohumeral kinematics during scaption. Correlations between the passive stiffness or strength of periscapular muscles and the kinematics or muscle activity were examined by Spearman's rank correlation coefficient. The maximal strength of periscapular muscles correlated positively with the ranges of upward and external rotation of the scapula and negatively with muscle activity during scaption. Passive stiffness of periscapular muscles was associated with the downward rotation of the scapula and triggered an increase in muscle activity. Increased passive stiffness or decreased strength in the periscapular muscles may affect their role in controlling the scapular rotation and contribute to compensation from adjacent muscles. Our findings suggest that when attempting to evaluate scapular behavior, it may be beneficial to examine muscle strength and passive stiffness of periscapular muscles.

Comparison of Strength and EMG Activity of Shoulder Flexor Muscles and Scapular Winging in Subjects with and without a Winged Scapula during Shoulder Flexion

Background Subjects with a winged scapula (WS) can cause musculoskeletal disorders of the shoulder due to uncontrolled movement of the scapula during shoulder flexion. A WS results in abnormal positioning of the scapula, leading to shoulder dysfunction. Objectives This study is to compare shoulder flexion strength, electromyography (EMG) activity of the periscapular muscles, and scapular winging during shoulder flexion in subjects with and without a WS. Methods Twelve with and thirteen without a WS participated in this study. To compare shoulder flexion strength, muscle activity, and scapular winging between the two groups, maximal flexion was measured using a tensiometer during shoulder flexion. Concurrently, surface EMG was used to measure the activities of the upper trapezius (UT), anterior deltoid (AD), serratus anterior (SA), and lower trapezius (LT) muscles, and a scapulometer was used to measure scapular winging during shoulder flexion. The independent t-test was used to compare shoulder flexion strength, muscle activity, and scapular winging between the two groups. Results There was no significant difference in shoulder flexion strength between the two groups (p = 0.172). The activities of the SA and UT muscles decreased significantly in subjects with a WS compared to subjects without a WS (p = 0.001 vs p = 0.023). In addition, scapular winging was significantly greater in subjects with a WS compared to those without a WS (p = 0.001). Conclusions These findings muscle activities of the SA and UT in subjects with WS is associated with upward rotation of the scapula and scapular winging rather than shoulder flexion strength. This may be supporting evidence for exercises reflecting the degree of activity of the muscles around the shoulders rather than focusing on the shoulder flexor during physical therapy related to shoulder flexion in a clinical setting.

Total Hip Arthroplasty in a Patient With Fascioscapulohumeral Dystrophy

Facioscapulohumeral dystrophy is an autosomal dominant disorder that results in progressive muscle weakness. Patients most commonly present with facial and periscapular muscle weakness, which progresses to involve their upper and lower extremities as well as truncal muscles. We present a patient with facioscapulohumeral dystrophy who underwent staged bilateral total hip arthroplasties but developed late prosthetic joint infection. This case also reports the management of periprosthetic joint infection after total hip arthroplasties through explant and placement of an articulating spacer as well as both neuraxial and general anesthetic management for this uncommon neuromuscular disorder.

Nonoperative treatment of shoulder pain

Background: The shoulder joint has a wide range of motion and is extensively used. Damage in its components may cause functional deficits and pain. In particular, shoulder joint pain is associated with discomfort due to the involvement of the joint’s movement in basic tasks of daily life, such as washing one’s hair, dressing, and eating.Current Concepts: Diseases that cause shoulder joint pain include shoulder impingement syndrome, rotator cuff tear and tendinopathy, lesion of superior labrum anterior to posterior, biceps tendinitis, adhesive capsulitis, calcific tendinitis, and shoulder instability. Nonoperative treatment of shoulder joint pain includes: (1) reducing pain and preventing structural damage through rest, lifestyle modification, and physical therapy; (2) reducing pain through drug and injection treatment; (3) strengthening the rotator cuff muscles, around the scapula; and (4) performing scapular stabilization treatment through muscle strengthening. These treatments maintain the biomechanics of the shoulder joint, prevent disease progression, and enable pain-free daily life and exercise through symptom relief.Discussion and Conclusion: It is necessary to have an accurate understanding of the structures that cause shoulder joint pain. Understanding the cause of the pain can prevent the disease from progressing. Nonoperative management for shoulder pain consists of preventing a decrease in the range of motion of the shoulder joint with reduction of pain relief, preventing inflammation through drug treatment, injection treatment, lifestyle modifications, and improving muscle strength of the muscles around the rotator cuff and periscapular muscle joint through rehabilitation exercise. Nonoperative treatment modalities are valuable and cost-effective management options for shoulder pain.

Clavicle lengthening, a novel operation technique to reduce pain in brachial plexus birth injury patients

Brachial plexus birth injury (BPBI) can lead to an imbalance of shoulder musculature that can lead to glenohumeral contractures, and joint and osseous deformities. Glenoid hypoplasia, lengthening of coracoid and acromion, protraction, lateral rotation and elevation of the scapula, and shortening of the clavicle can be observed. As a consequence, the trapezius, levator scapulae, rhomboid, and supraspinatus muscles are overloaded in daily activities causing pain, which can be difficult to treat conservatively. It is hypothesized that operative lengthening of the clavicle may lead to a more anatomic position of the scapula and periscapular muscles, which, as a consequence, may lead to less overloading pain. This study presents the results of this new technique in patients with BPBI. Seven patients (median age 20 years) were included and underwent a lengthening osteotomy of the clavicle at the affective side. Preoperatively, the osseous deformities were confirmed with a computed tomography scan. Patient-reported outcome measures, Disabilities of Arm, Shoulder and Hand score, and Mallet score were evaluated pre- and postoperatively. After a median of 42 (interquartile range [IQR]: 8.0) months' follow-up, all patients were satisfied with the result. The median numeric rating scale for satisfaction was 8.0 (IQR: 2). Pain decreased from a median numeric rating scale of 7.0 (IQR: 2) preoperatively to 2.0 (IQR: 3) at the final follow-up. The median Mallet score was 14.5 (IQR: 1) preoperatively and 14 (IQR: 0) at the final follow-up. The median Disabilities of Arm, Shoulder and Hand score was 36.7 (IQR: 24.1) at the final follow-up. All patients returned to their normal work without changes in working conditions. Short-term follow-up shows that in patients with BPBI with a short clavicle at the affected side and malposition of the scapula, a lengthening osteotomy of the clavicle is a safe and promising technique to reduce pain based on overloading, without deterioration of shoulder function.

Management of scapular dysfunction in facioscapulohumeral muscular dystrophy: the biomechanics of winging, arthrodesis indications, techniques and outcomes.

Facioscapulohumeral muscular dystrophy (FSHD) is a common hereditary disorder which typically results in scapular winging due to wasting of the periscapular muscles affected by this condition. Scapulothoracic arthrodesis (STA) is the current surgical treatment for FSHD patients with severe winging and preserved deltoid muscle. There are several different techniques in the literature such as multifilament cables alone and cable or cerclage wires combined with single or multiple plates. We prefer cables without plates as it provides independent strong fixation points and strongly recommend utilization of autograft. The functional results of studies report that regardless of the technique used, shoulder elevation and thus quality of life is improved, as shown with outcome scores. There are several complications associated with STA. Pulmonary complications are common and usually resolve spontaneously. Meticulous surgical technique and effective postoperative analgesia may reduce the incidence. Scapular complications which are associated with the fixation may be encountered in the early or late period, which are related to the learning curve of the surgeon. In conclusion, STA is a reliable solution to a major problem in FSHD patients that helps them maintain their activities of daily living until a cure for the disease is found. A successful result is strongly dependent on patient selection, and a multidisciplinary team of neurologists, geneticists and orthopaedic surgeons is required to achieve good results.

Arthroscopic Treatment of Chronic Acromioclavicular Dislocation With Semitendinosus Autograft and Coracoclavicular Suspension Fixation

The management of acromioclavicular dislocations remains controversial. On many occasions, these chronic dislocations are asymptomatic. However, there are patients who, despite good rehabilitation treatment, do present with pain, periscapular muscle fatigue, weakness, paresthesia or scapular dyskinesia. In these patients, surgical treatment is indicated.

Efficacy of radial extracorporeal shockwave therapy in rehabilitation following arthroscopic rotator cuff repair: A STROBE compliant study.

Rotator cuff tear is a common cause of shoulder pain and disability. Arthroscopic rotator cuff repair (ARCR) is performed to treat a torn tendon. Postoperative joint immobilization is essential, but it is a problem that needs to be addressed in the rehabilitation process. This study aimed to evaluate the effects of radial extracorporeal shock wave therapy (rESWT) in patients who underwent ARCR and required active movement after the immobilization period. This study was an open-label, prospective, single-arm trial of 30 inpatients aged >18 years who underwent ARCR. A total of 6 rESWT sessions, along with the conventional rehabilitation program for ARCR patients, were provided at the hospital’s sports rehabilitation center for 2 weeks. The application sites of rESWT are periscapular muscles (supraspinatus, infraspinatus, teres minor, and rhomboid). Evaluations were conducted 3 time points—baseline, immediately after the first session of rESWT, and after 2 weeks of intervention. The outcome measures were the numeric pain rating scale for pain, and shoulder flexion, scaption flexion, abduction, horizontal adduction, external rotation, and internal rotation for shoulder range of motion. For shoulder function, disabilities of the arm, shoulder and hand, shoulder pain and disability index, and simple shoulder test were used, and muscle strength was expressed by grip strength. supraspinatus and infraspinatus evaluated thickness, tone, and stiffness. The muscle strength (95% CI, –3.554 to –0.073) and supraspinatus tone (P = .017) showed significant changes immediately after the first session of rESWT. Further, there was significant improvement in ROM (P < .01); shoulder function (P < .01); and muscle strength (95% CI, –3.561 to –0.625), supraspinatus stiffness (95% CI, –67.455 to –26.345), and infraspinatus stiffness (P = .045) after 2 weeks of intervention. However, muscle thickness and tone were significantly improved only in supraspinatus (P = .044, P = .040). Rehabilitation with radial extracorporeal shock wave therapy additionally applied to the periscapular muscles in patients who started active movement in rehabilitation after arthroscopic rotator cuff repair is effective for shoulder function and muscle properties (muscle strength, thickness, tone, and stiffness). However, a randomized controlled trial is needed to further assess the effects of radial extracorporeal shock wave therapy alone.

Bilateral glenohumeral internal rotation deficit (GIRD) in elite gymnasts

IntroductionThe “Glenohumeral Internal Rotation Deficit (GIRD)” is known as the difference in internal rotation range of motion (IRRM) between the dominant and non-dominant shoulder of overhead athletes as a result of asymmetric loading. As in contrast loading pattern in gymnastics are quite symmetric and structural changes often occur bilaterally, the question arises if GIRD might develop bilaterally in gymnasts as one source of common bilateral shoulder pathologies and to search for underlying structural adaptations.Materials and methodsA group of 35 elite gymnasts (8–24 years) were recruited from a local Olympic Training Centre and compared to a paired cohort of 28 non-overhead athletes. Clinical examinations, digital range of motion (ROM)-measurement, ultrasonographic humeral torsion measurement, and standardized MRI scans of both shoulders were obtained and examined for structural pathologies, cross-sectional areas (CSA) of the rotator cuff muscles and capsular thickness.ResultsROM-measurements showed significant decrease in IRRM in the gymnasts groups by age, with IRRM of 48.6° (SD: 8.4°, CI 95%: 43.0–54.3°) at age group 1 (8–10 years) and IRRM of 10° (SD: 11.4°; CI 95%: 0–22.0°) at age group 4 (18–26 years), that was statistically significant for the entire cohort (p = 0.017) compared to the controls. CSA were not significantly different between the cohorts, while there was a slightly increased humeral retrotorsion in the gymnasts as well as a statistically significant posterior capsular thickening.ConclusionA new bilateral form of GIRD was identified in higher age groups of youth and senior elite gymnasts enrolled in this study. Despite to former definition of GIRD there was no compensatory increase in external rotation range of motion (ERRM) but an association with posterior capsular thickening, while there was no periscapular muscle hypertrophy. Humeral retrotorsion was also slightly increased in the gymnasts group.

Comprehensive management of posterior shoulder instability: diagnosis, indications, and technique for arthroscopic bone block augmentation.

Recurrent posterior glenohumeral instability is an entity that demands a high clinical suspicion and a detailed study for a correct approach and treatment. Its classification must consider its biomechanics, whether it is due to functional muscular imbalance or to structural changes, volition, and intentionality.Due to its varied clinical presentations and different structural alterations, ranging from capsule-labral lesions and bone defects to glenoid dysplasia and retroversion, the different treatment alternatives available have historically had a high incidence of failure.A detailed radiographic assessment, with both CT and MRI, with a precise assessment of glenoid and humeral bone defects and of glenoid morphology, is mandatory.Physiotherapy focused on periscapular muscle reeducation and external rotator strengthening is always the first line of treatment. When conservative treatment fails, surgical treatment must be guided by the structural lesions present, ranging from soft tissue repair to posterior bone block techniques to restore or increase the articular surface.Bone block procedures are indicated in cases of recurrent posterior instability after the failure of conservative treatment or soft tissue techniques, as well as symptomatic demonstrable nonintentional instability, presence of a posterior glenoid defect >10%, increased glenoid retroversion between 10 and 25°, and posterior rim dysplasia. Bone block fixation techniques that avoid screws and metal allow for satisfactory initial clinical results in a safe and reproducible way.An algorithm for the approach and treatment of recurrent posterior glenohumeral instability is presented, as well as the author’s preferred surgical technique for arthroscopic posterior bone block.

Outcome of arthroscopic pectoralis minor release and scapulopexy for the management of scapulothoracic abnormal motion.

Management of persistent symptomatic scapulothoracic abnormal motion (STAM) in the absence of periscapular muscle paralysis may be challenging. This study reports the outcomes of arthroscopic pectoralis minor release and scapulopexy for the management of symptomatic STAM secondary to pectoralis minor hyperactivity and serratus anterior hypoactivity in the absence of periscapular paralysis. This was a retrospective cohort study with prospectively collected data of patients with symptomatic STAM secondary to pectoralis minor hyperactivity and serratus anterior hypoactivity. Surgery was indicated if patients failed 6 months of conservative management. Patient outcomes were assessed with shoulder range of motion (ROM) measurements, numerical pain scale, shoulder subjective value (SSV), and Constant score. Data were analyzed with Fischer's exact test for categorical variables and Student's t-test of unequal variance for continuous and categorical variables. Thirty-one consecutive patients were included in the study period between 2017 and 2020. Average age at the time of surgery was 24 years (range, 14-44 years), 80% of patients were female, and average follow-up after surgery was 23 months (range, 15-39 months). Thirteen patients also had a diagnosis of recurrent posterior instability. At final follow-up, 81% reported significant improvements in their STAM, as demonstrated by improved mean pain scale, ROM, SSV, and Constant scores. Pain improved from 6 (range, 4-10) to 2 (range, 1-4), SSV from 30% (range, 10%-40%) to 75% (range, 60%-100%), and Constant score from 49 (range, 43-61) preoperatively to 79 (range, 51-100) postoperatively (P < .01). All 13 patients with recurrent associated posterior instability had resolution of their instability. Flexion ROM improved from average 100° (range, 60°-150°) to 140° (range, 120°-160°). One patient had traumatic rupture of her scapulopexy 7 weeks postoperatively and underwent revision scapulopexy. Thirteen percent had minimal improvement after surgery and experienced recurrence 3 months postoperatively. In patients with symptomatic STAM secondary to pectoralis minor hyperactivity and serratus anterior hypoactivity, arthroscopic pectoralis minor release and scapulopexy is an effective surgical option.

Causal mechanisms of a scapular stabilization intervention for patients with subacromial pain syndrome: a secondary analysis of a randomized controlled trial

BackgroundCausal mediation analysis is one way to bridge this gap by exploring the causal pathways of a given intervention. The aim of this study was to assess whether scapular motion, position, and periscapular muscle strength are mediators for pain and shoulder disability outcomes following a scapular stabilization intervention for patients with subacromial pain syndrome.MethodsSixty patients were randomized into two groups: scapular stabilization or periscapular strengthening exercises. The intervention consisted of three sessions per week for 8 weeks. The primary outcome measures were pain and disability and the following outcome measures were considered as potential mediators: scapular motion, scapular position, periscapular muscle strength, age, duration of symptoms, and side of the complaint. A model-based inference approach with bootstrap simulations was used to estimate the average causal mediation effect, average direct effect, and the average total effect from the data of a randomized clinical trial that evaluated the effect of adding scapular stabilization exercises to a scapulothoracic strengthening program in people with subacromial pain syndrome.ResultsThe results demonstrated that none of the putative mediators were influenced by the intervention. However, muscle strength of serratus anterior, upper, middle, and lower trapezius muscles was associated with shoulder disability.ConclusionScapular kinematic and periscapular muscle strength did not mediate the effect of scapular stabilization exercises on shoulder pain or disability scores in subjects with subacromial pain syndrome. Muscle strength of serratus anterior, upper, middle and lower trapezius were associated with shoulder disability scores at 8-weeks follow-up.

Comparison of Core Muscle Asymmetry Using Spine Balance 3D in Patients with Arthroscopic Shoulder Surgery: A STROBE-Compliant Cross-Sectional Study

Background and Objectives: Joint immobilization after shoulder surgery can cause an imbalance in the periscapular muscles and affect the kinetic chain throughout the body. There is a difference in core muscle stability because of the asymmetry of the lower extremity muscles. However, the difference due to the asymmetry of the upper-extremity muscles has not been studied extensively. The purpose of this study is to investigate the effect of joint immobilization on the symmetry of the core muscles involved in proximal stability for distal mobility. Materials and Methods: Fifty-five patients who underwent arthroscopic shoulder surgery participated in this study. Core muscle asymmetry (CMA) was measured using a body tilt device. The evaluation variables were analyzed according to the surgical site based on the direction of the core muscle ratio and core muscle state ratio. Results: No differences in CMA were found based on the surgical site (p > 0.05). As a result of the additional subanalysis, significant differences in sex and postoperative day were established (p < 0.05). CMA was low during the intensive postoperative rehabilitation period. However, sex-related differences were greater in males than in females. Conclusions: The clinical results suggest that core muscle training is necessary to reduce CMA during rehabilitation after the immobilization period has elapsed.

Correlation between upper limb function and clinical measures of shoulder and trunk mobility and strength in overhead athletes with shoulder pain

ObjectiveTo investigate the correlation between functional performance and self-reported upper limb function and between these two functional measures and clinical measures of shoulder and trunk in overhead athletes with shoulder pain. DesignCross-sectional study. SettingsLaboratory. ParticipantsTwenty-one volleyball and handball athletes (23.6 ± 3.7 years) with shoulder pain in the dominant limb. Main outcome measuresSelf-reported dominant upper limb function using Penn Shoulder Score and Disabilities of the Arm, Shoulder, and Hand; shoulder and trunk range of motion; isometric strength of shoulder, periscapular, and trunk muscles; endurance time of trunk muscles; and functional upper limb performance using the Upper Quarter Y-Balance Test (UQYBT). ResultsA moderate correlation was observed (r = 0.45–0.58; p < 0.05) between UQYBT performance and strength of serratus anterior, lower trapezius, trunk rotators, and trunk flexors. No significant correlation was observed between UQYBT performance and the other clinical measures of shoulder and trunk (r = 0.01–0.39, p > 0.05). Self-reported upper limb function was neither significantly correlated with clinical measures (r = 0.01–0.40, p > 0.05) nor with UQYBT performance (r = 0.02–0.19, p > 0.05). ConclusionWe observed a correlation between UQYBT performance and strength of periscapular and trunk muscles.

Inferior angle of scapula fractures: A retrospective case series

Background: Inferior angle of scapula fractures (IAS) are rare injuries that result from the periscapular shoulder muscles avulsing the inferior scapula tip. The aim of this study was to investigate the mechanisms of injury, investigations and treatment outcomes, as currently only case reports are available to guide management. Methods: Computered tomography (CT) images were reviewed to identify patients with an IAS fracture. Case notes were reviewed, and patients contacted to gather data relating to the injury, treatment and outcome. Results: Fourteen fractures were identified on CT. Five were missed on the initial radiograph. High energy fractures had an average age of 47.6 years, 90% were male. Low energy fractures had a mean age of 83.6 years 75% were female. All undisplaced fractures had a satisfactory outcome treated non-operatively. Three of six displaced fractures reported an unsatisfactory outcome with non-operative treatment. Subsequent surgical fixation resulted in resolution of symptoms. Conclusions: Inferior angle of scapula fractures are a rare injury that can result from high or low energy trauma. They are easy to miss on plain radiographs. Identification is important as displaced fractures can do poorly when treated non-operatively, but symptoms resolve with surgical fixation. Undisplaced fracture has a satisfactory outcome when treated non-operatively. Evidence: Level IV.

Relação da discinese scapular com o padrão de ativação dos músculos periescapulares durante exercicios

abstract The aim of the present study was to analyze the activation pattern of the serratus anterior (SA), upper trapezius (UT), and lower trapezius (LT) muscles during periscapular exercises in individuals with and without ED, and to identify which proposed exercise presents greater activation of the periscapular muscles. Fourteen women, aged between 18 and 30 years, participated in this study, divided into a control group (n = 8) and a dyskinesis group (n = 8). The determination of the presence of ED was performed according to the analysis of scapular movement during arm elevation, using the yes/no classification. To evaluate muscle activation, electromyography signals of the SA, UT, and LT muscles were collected during exercise. The exercise protocol was composed of three repetitions of the exercises: punch up, wall slide, and scaption. The results showed that the ED group showed less activation of the AS and TT than the control group. During the scaption and wall slide exercises, the DE group showed less activation of the AS in relation to those without DE. There was no difference in muscle activation between the exercises. That individuals with dyskinesis have less activation of the muscles that control scapular mechanics and that the type of exercise did not influence the activation of the periscapular muscles.

Scapulectomy for Fibromatosis – Ocological and Functional Outcomes

Aggressive fibromatosis is a locally invasive tumor that does not metastasize. Only few cases of scapulectomy for fibromatosis of scapular muscles are reported in the world literature. We present two consecutive cases of scapulectomy done for fibromatosis of periscapular muscles at the Department of Surgical Oncology in our centre between 2014 and 2019. One patient underwent subtotal scapulectomy by posterior approach and the other patient underwent scapulectomy below spine of scapula by combined anterior and posterior approach. The follow-up period of both the patients was 5 years. One patient developed recurrence after 9 months of surgery dealt by re-resection followed by adjuvant radiation. The modified Musculoskeletal Tumor Society (MSTS) score for scapular surgery was 20 in the first patient and 22 in the second patient. Both of them are able to carry out normal regular activities with the compensation from the opposite upper limb. Scapulectomy for symptomatic fibromatosis of the scapular muscles gives acceptable functional results and good disease-free interval. Scapulectomy should be considered as part of resection for better tumor clearance in fibromatosis involving muscles around the scapula. Further studies are needed to evaluate and validate the need for radical surgery in this setting.

Arthroscopically Assisted Stabilization of Chronic Acromioclavicular Joint Instability.

For this procedure, the patient is placed in the beach chair position. After establishing standard posterior, anteroinferior, and anterolateral (transtendinous) portals, the arthroscopic preparation of the coracoid base is performed. Next, transcoracoidal-transclavicular drilling is performed, and a nitinol suture passing wire is utilized to aid the placement of the TightRope later in the procedure. The graft passage around the clavicle and the coracoid is then set up by placing 2 additional nitinol suture passing wires. Following this, coracoclavicular stabilization is performed with use of the low-profile TightRope device, after which the graft is shuttled around the clavicle and the coracoid with the help of the passing wires. After the acromial drilling, the graft is shuttled laterally transacromially and subcutaneously back to the clavicle, completing the AC cerclage. Finally, the graft ends are sewn together under tension. The deltotrapezial fascia is closed above the graft, incorporating the tendon ends into the suture. Finally, the skin can be closed. In case of chronic AC joint injuries, many surgical stabilization techniques have been described. On the one hand there are rigid stabilization techniques like the hook-plate or temporary Kirschner wire fixation. On the other hand, there are dynamic stabilization techniques like the modified Weaver-Dunn procedure or solitary synthetic coracoclavicular reconstruction with use of pulley-like devices, with or without additional AC stabilization3. As for nonsurgical alternatives, physiotherapy with periscapular stabilization and muscle strengthening may be an option4. For the treatment of chronic AC joint instability, many techniques5-9 have been described that utilized horizontal and vertical stabilization with a tendon graft combined with a synthetic pulley-like device. Usually, multiple transclavicular and transcoracoidal drill holes are utilized for the graft passage, which could weaken the bone and may result in postoperative fractures of the coracoid and clavicle10. Considering this, we present a modified technique that focuses on the optimization of the graft passage. In contrast to other aforementioned techniques, this procedure requires only 1 transcoracoidal-transclavicular tunnel for the TightRope and another transacromial tunnel for the passage of the AC cerclage. By forming a loop of the graft around the coracoid and the clavicle, the graft passage is managed without any additional coracoidal or clavicular drilling. A dedicated study investigating the specific clinical and radiographic results of our technique will be part of future research. Because the biomechanical principle of reconstruction of our technique is very similar to the technique described by Kraus et al., we refer to their clinical and radiographic results regarding the expected outcome. As shown in the chart in the video, Kraus et al. demonstrated good clinical and radiographic results with their biologic and synthetic AC-stabilization technique at a median follow-up of 24 months. The outcomes measured in that study were the Constant score, Subjective Shoulder Value, AC Joint Instability Score, and Taft score. Patients were divided into 2 groups. Group 1 included patients with failed prior conservative treatment, and group 2 included those with failed prior surgical treatment. Overall, the authors report complete dynamic posterior translation in 1 patient and partial dynamic posterior translation in 5 patients. Although there was no notable enlargement of the TightRope drill hole, the authors of that study found a significant enlargement of the clavicular graft tunnels. However, the enlargement had no clinical relevance10. Utilize a low-profile TightRope device to minimize the risk of suture irritation from knot stacks.The tendon graft should be ≥24 cm in length. If the graft is too short, perform an end-to-end anastomosis of 2 grafts.Utilize an image intensifier to ensure correct drill hole placement and avoid damage to neurovascular structures.The graft passage around the clavicle and the coracoid can be dilated by hand with the use of differently sized drill bits.Incorporate the graft into fascial closure at the end of the procedure.

Physiotherapy Rehabilitation in Subjects Diagnosed with Subacromial Impingement Syndrome Does Not Normalize Periscapular and Rotator Cuff Muscle Onset Time of Activation.

Clinicians suggest that rehabilitation of Subacromial Impingement Syndrome (SIS) should target improving movement patterns to ensure better clinical outcomes. Understanding changes in onset time of activation patterns and associated changes in clinical outcomes could improve our understanding of rehabilitation strategies. In this prospective longitudinal study, we examined neuromuscular firing patterns and clinical features before and after a standardized physiotherapy program in subjects diagnosed with SIS. Electromyography (EMG) recordings of eleven shoulder muscles were taken at the initial and discharge consultation in 34 male volunteers diagnosed with SIS. EMG recording was performed during flexion, scaption, and abduction at slow, medium, and fast speeds with a loaded (3 kg) and unloaded arm, as well as rotational motion, rotational strength, pain, and shoulder function. Completion of standardized shoulder physiotherapy program for SIS resulted in improvements in clinical outcomes. Resulted showed inconsistent differences of onset time of activation mainly in some of the periscapular muscles for all movements. No differences were seen on the EMG recordings for rotator cuff muscles. Differences in range of motion, strength and function were shown. Despite some changes in onset time of activation, this study was not able to demonstrate consistent changes of onset time of activation of the periscapular and rotator cuff muscles.

Electromyographic Analysis of a Selective Exercise for the Serratus Anterior Muscle Among Patients With Frozen Shoulder and Subacromial Impingement Syndrome.

Patients with shoulder disorders show altered periscapular muscle activity (e.g., decreased serratus anterior and increased upper trapezius activities). We herein devised a novel method for strengthening serratus anterior without excessive upper trapezius activation, named squeezing ball exercise in which patients squeezed a ball between both elbows with maximum voluntary isometric contraction in the horizontal adduction direction with the arms elevated at a 45-degree angle. The present study aimed to investigate whether the squeezing ball exercise could produce high muscle activity in the serratus anterior in patients with frozen shoulder and subacromial impingement syndrome before the rehabilitation intervention. This is a proof-of-concept study. Serratus anterior and upper trapezius activities during squeezing ball exercise were evaluated using electromyography in 16 patients with frozen shoulders and subacromial impingement syndrome. Electromyography signals were normalized using maximal voluntary isometric contraction, and the muscle balance ratios (upper trapezius/serratus anterior) were calculated. The average serratus anterior and upper trapezius activity was 69.9% ± 30.8% and 10.2% ± 6.3% maximal voluntary isometric contraction during the squeezing ball exercise, respectively, whereas the upper trapezius-serratus anterior ratio of the affected side was 0.15 ± 0.07. The high serratus anterior activation and low upper trapezius-serratus anterior ratio during squeezing ball exercise could be attributed to the limb position where shortened serratus anterior exerts itself without painful subacromial impingement. Squeezing ball exercise could be a novel rehabilitation tool for patients with frozen shoulders and subacromial impingement syndrome.