Scapula fractures: functional anatomy, clinical assessment and management.

Fractures of the scapula are rare injuries, accounting for 3-5% of all shoulder girdle fractures. They are frequently the result of high energy trauma and often present with concurrent and life-threatening injuries to adjacent structures, leading to significant morbidity and mortality. Patients presenting with scapula fractures must receive a thorough and systematic clinical assessment as directed by national trauma guidelines. Appropriate imaging is essential in delineating fracture morphology and should at the very least include anteroposterior, anteroposterior oblique (Grashey) and axillary or scapula 'Y' view of the shoulder. Computed tomography imaging with three-dimensional reconstruction allows better delineation of the fracture morphology and helps with surgical planning. A lack of randomised controlled trials comparing the efficacy of conservative and operative management of scapula fractures has resulted in limited consensus for surgical indications. Nevertheless, most extra-articular fractures can be managed conservatively while intra-articular fractures of the glenoid frequently require surgical fixation.

A Morphometric Study of Glenoid Cavity of Scapula in Bangladeshi Population.

This cross-sectional descriptive purposive study was conducted among 150 (70 right and 80 left) fully ossified dry human scapulae of Bangladeshi people from January 2019 to December 2019 in the Department of Anatomy, Mymensingh Medical College, Mymensingh. Shape of the glenoid cavity was observed as pear, oval or inverted comma shape. Morphometric parameters such as length and breadth of glenoid cavity were measured by digital Vernier slide calipers. In this study, 19.13% cases were found inverted comma shaped, 35.65% cases were oval and 45.22% cases were pear shaped. The mean±SD length of glenoid cavity was 37.5±3.61 mm and 36.19±3.68 mm on right and left sided scapulae respectively and mean±SD breadth was 23.6±2.73 mm on right and 23.42±2.75 mm on left side respectively. Mean±SD glenoid cavity index was 62.89±4.39 on right and 64.61±4.74 on left sided scapulae. Morphometric analysis of glenoid fossa of scapula might help clinicians in shoulder and its associated diseases.

Biomechanical Characteristics of Glenosphere Orientation Based on Tilting Angle and Overhang Changes in Reverse Shoulder Arthroplasty.

Background: Glenoid position and inclination are important factors in protecting against scapular notching, which is the most common complication that directly affects the longevity of reverse shoulder arthroplasty (RSA). This study aimed to investigate the biomechanical characteristics of glenosphere orientation, comparing neutral tilt, inferior overhang with an eccentric glenosphere at the same placement of baseplate, and inferior tilt after 10° inferior reaming in the lower part of the glenoid in RSA. Methods: Nine cadaveric shoulders were tested with 5 combinations of customized glenoid components: a centric glenosphere was combined with a standard baseplate (group A); an eccentric glenosphere to provide 4-mm inferior overhang than the centric glenosphere was combined with a standard baseplate (group B); a centric glenosphere was combined with a wedge-shaped baseplate tilted inferiorly by 10° with the same center of rotation (group C); an eccentric glenosphere was attached to a wedge-shaped baseplate (group D); and 10° inferior reaming was performed on the lower part of the glenoid to apply 10° inferior tilt, with a centric glenosphere secured to the standard baseplate for simulation of clinical tilt (group E). Impingement-free angles for adduction, abduction, forward flexion, external rotation, and internal rotation were measured. The capability of the deltoid moment arm for abduction and forward flexion, deltoid length, and geometric analysis for adduction engagement were evaluated. Results: Compared with neutral tilt, inferior tilt at the same position showed no significant difference in impingement-free angle, moment arm capability, and deltoid length. However, group D resulted in better biomechanical properties than a central position, regardless of inferior tilt. Group E demonstrated a greater range of adduction, internal and external rotation, and higher abduction and forward flexion capability with distalization, compared to corresponding parameters for inferior tilt with a customized wedge-shaped baseplate. Conclusions: A 10° inferior tilt of the glenosphere, without changing the position of the baseplate, had no benefit in terms of the impingement-free angle and deltoid moment arm. However, an eccentric glenosphere had a significant advantage, regardless of inferior tilt. Inferior tilt through 10° inferior reaming showed better biomechanical results than neutral tilt due to the distalization effect.

Effects of scapular treatment on chronic neck pain: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Chronic neck pain (CNP) is a common public health problem that affects daily living activities and quality of life. There is biomechanical interdependence between the neck and scapula. Studies have shown that shoulder blade function might be related to chronic neck pain. We therefore evaluated the effects of scapular targeted therapy on neck pain and function in patients with CNP. METHODS: Databases, including MEDLINE (via PubMed), EMBASE (via Ovid), Ovid, Web of Science, and Scopus, were systematically searched for randomized controlled trials published in English investigating treatment of the scapula for CNP before July 16, 2023. RESULTS: A total of 313 participants were included from 8 RCTs. Compared with those in the control group, the intervention in the scapular treatment group exhibited greater improvement in pain intensity (standardized mean difference (SMD) = 2.55; 95% CI = 0.97 to 4.13; P = 0.002), with moderate evidence. Subgroup analysis for pain intensity revealed a significant difference between the sexes, with only the female population (SMD = 6.23, 95% CI = 4.80 to 7.65) showing better outcomes than those with both sexes (SMD = 1.07, 95% CI = 0.57 to 1.56) (p < 0.00001). However, moderate evidence demonstrated no improvement in neck disability after scapular treatment (SMD of 0.24[-0.14, 0.62] of Neck Disability Index or Northwick Park Neck Pain Questionnaire). No effect of scapular treatment was shown on the pressure pain threshold (PPT). The cervical range of motion (CROM) and electromyographic activity of neck muscles could not be conclusively evaluated due to limited support in the articles, and further study was needed. However, the patient's head forward posture appeared to be corrected after scapular treatment. CONCLUSION: Scapular therapy was beneficial for relieving pain intensity in patients with CNP, especially in women. Head forward posture might also be corrected with scapular therapy. However, scapular therapy may have no effect on the PPT or neck disability. However, whether scapular therapy could improve CROM and cervical muscle activation in patients with CNPs had not been determined and needed further study.

Complications and Reinterventions of Reverse Total Shoulder Arthroplasty in a Korean Population: 14-Year Experience in Reverse Shoulder Arthroplasty.

Background: There are few reports on the revision or reintervention of reverse total shoulder arthroplasty (RTSA) in South Korea. The purpose of this study was to evaluate the true incidence of complications and reintervention of RTSA and clinical and radiological outcomes based on our 14-year experience in RTSA in a Korean population. Methods: Between March 2008 and June 2022, 412 consecutive cases of RTSA were performed in 388 patients with an average age of 74.4 years at our institute. Excluding 23 patients lost to follow-up, 365 patients (373 shoulders including 8 bilateral cases) who underwent primary RTSA with more than 6 months of follow-up were enrolled in this study. We evaluated those who had complications or reintervention including revision RTSA for failed RTSA. Patient charts were reviewed, and clinical outcomes including clinical scores, complications, and reintervention and radiologic outcomes were evaluated at the last follow-up. Results: Among the 373 shoulders that underwent primary RTSA, complications were found in 50 patients (13.94%, 10 men and 40 women with a mean age of 75.9 ± 6.7 years [range, 51-87 years]). The causes of complications were as follows: 13 acromion, coracoid, or scapular spine fractures, 10 loosening (glenoid: 5, humeral stem: 5), 5 infections, 4 periprosthetic fractures, 2 instability, 2 neurologic complications, and 14 miscellaneous complications. Twenty patients (5.63%, 4 men and 16 women with a mean age of 74.2 ± 8.2 years [range, 51-87 years]) underwent reintervention. The interval to the first reintervention was 27.8 ± 23.1 months (range, 0.1-78 months). The causes of reintervention (20 cases) were 8 loosening (glenoid: 4, humeral stem: 4), 5 infections, 5 fractures, and 2 instability. Among them, 15 component revisions (4.02%) were performed. At the last follow-up, American Shoulder and Elbow Surgeons, University of California at Los Angeles, and Simple Shoulder Test scores were improved from 25.4, 12.4, and 1.6 preoperatively to 40.4, 16.2, and 3.2, respectively. Forward flexion (48° to 87°), abduction (52° to 79°), external rotation (18° to 22°), and internal rotation (buttock to L2) were improved. Conclusions: After primary RTSA in a Korean population, the complication, reintervention, and revision rates were 13.94%, 5.63%, and 4.02%, respectively. Careful evaluation of the complications and adequate treatments should be performed.

The Association between SLAP Lesions and Critical Shoulder Angle and Glenoid Depth.

PURPOSE OF THE STUDY: The critical shoulder angle (CSA) is formed by the combination of glenoid inclination and acromial index and has been shown related to rotator cuff tears and glenohumeral osteoarthritis. SLAP lesions today have an important place among bicipitolabral pathologies that cause intensive shoulder pain. We aimed to investigate the relationship between CSA and glenoid depth and SLAP lesions. MATERIAL AND METHODS: Between March 2017 and January 2022, 279 consecutive shoulder arthroscopy patients' MRI images were retrospectively examined. After the exclusion criteria, 191 patients were eligible. Patients with SLAP lesions (n=37) were assembled as the study group (Group 1), and patients with intact superior labrum (n=154) were named as the control group (Group 2). Critical shoulder angle (CSA) and glenoid depth measurements were performed using the preoperative MRI images. RESULTS: A total of 191 patients, of whom 84 were male (44%) were included. The mean age was 49.9±14.96 (range 18-79). There was a statistically signifi cant difference between the SLAP group (Group 1) and the control group (Group 2) in terms of CSA (p=0.032). The mean CSA was 31.66°±3.51° in Group 1 and 33.57° ±5.01° in Group 2. The cut-off value for CSA in patients with SLAP lesions was calculated as 32.85° and the area under the curve was 0.61, therefore a satisfactory association was observed between the groups. The mean glenoid depth was 4.32 ±1.25 mm in Group 1, and 4.39 ±0.32 mm in Group 2. There was no statistically signifi cant difference between the groups in terms of glenoid depth (p=0.136) and also no association between the glenoid depth and SLAP lesions was observed (cut-off=4.45 mm, AUC=0.32). CONCLUSIONS: Low CSA is associated with SLAP lesions, just as in glenohumeral osteoarthritis. Further prospective clinical studies are needed to enlighten the predisposing effect of CSA to SLAP lesions and the success of superior labral repairs. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.

Posterior deltoid-sparing approach for displaced inferior or posterior glenoid fossa fractures: technical note and case series.

Scapular surgery has usually been performed through the posterior Judet approach. This approach allows access to the entire posterior scapular body, but causes significant soft tissue damage and detaches the deltoid muscle. To date, there has been no clinical study of a deltoid-preserving approach to access the joint for displaced postero-inferior glenoid fractures (Ideberg type II or Ib). We describe an easy and less invasive approach to the postero-inferior glenoid fossa.

External handheld loads affect scapular elevation and upward rotation during shoulder elevation tasks.

Altered scapular kinematics is associated with shoulder pain. Resistance exercise is a common treatment; however, the effects of lifting an external load on scapular kinematics is limited. Understanding whether an external handheld load affects scapular kinematics in a healthy population can provide normal values utilized for comparison to individuals with shoulder pain. Currently, no studies have examined the effect of incrementally increased handheld loads. We defined the effects of varying external handheld loads on scapular kinematics during a shoulder elevation task. Healthy participants (n = 50) elevated their shoulder in the scapular plane over 4 trials. One trial of no loading (control) and 3 trials with incrementally increased external handheld loads. Scapular kinematic rotations and translations were measured during ascent and descent phases using 3D motion capture. Compared to no load, the highest external load during ascent increased scapular elevation [mean difference = 3.2 degrees (95%CI: 0.9, 5.4), p = 0.006], and during descent increased scapular elevation [mean difference = 3.9 degrees (95%CI: 2.8, 5.1), p < 0.001] and increased scapular upward rotation [mean difference = 4.5 degrees (95%CI: 2.4, 6.6), p < 0.001]. External handheld loads result in small increases in scapular elevation and scapular upward rotation. These results should be utilized as normal values to compare to individuals with shoulder pain.

The latissimus dorsi creates a dynamic track for the inferior angle of the scapula during arm abduction in humans.

BACKGROUND: The importance of several scapulothoracic muscles, including trapezius and serratus anterior, in maintaining physiological scapula kinematics has been highlighted in the past. However, the relationship between the scapula and the latissimus dorsi muscle remains unclear. Our clinical surgical observation is that the latissimus dorsi does not directly attach but rather runs superficial to the inferior angle of the scapula. Based on this observation, we hypothesise that the latissimus dorsi creates a dynamic track on which the scapula glides under the muscle belly during elevation of the arm, creating the latissimus-scapula overlap (LSO). METHODS: All consecutive patients who had a whole-body computed tomography scan (CT) in case of polytrauma evaluation between 2018 and 2021, with complete depiction of the scapula and latissimus dorsi muscle, were analysed. 150 shoulders in 90 patients with arms up were matched according to their age (within five years), gender, and affected side with 150 shoulders in 88 patients with arms down. Patients with pathologies of the upper extremities or thorax that potentially could alter LSO measurements were excluded. LSO was calculated as a ratio of the measured area of the latissimus dorsi projection on the scapula and the total scapula area. RESULTS: The mean age of the 178 patients (48 females; 13 males) was 60 years. The arms-up group showed a significantly higher LSO than the arms-down group (19.9 ± 6.3% vs. 2.7 ± 2.2%; p < 0.0001). In the arms-up group, approximately one fifth of the scapula was overlapped inferiorly by the muscle belly of the latissimus dorsi, contrary to the almost non-existing LSO in the arms-down group. CONCLUSION: With arms up, humans show a significantly higher LSO in comparison to arms down indicating that the latissimus dorsi indeed creates a dynamic track on which the scapula is forced to travel during abduction of the arm. This finding of increased LSO during the elevation of the arm warrants further consideration of the role of the latissimus dorsi in scapula kinematics and potentially scapular dyskinesis. LEVEL OF EVIDENCE: Level two diagnostic study.

Risk of suprascapular nerve injury in open Trillat procedure: an anatomical study.

PURPOSE: The open Trillat Procedure described to treat recurrent shoulder instability, has a renewed interest with the advent of arthroscopy. The suprascapular nerve (SSN) is theoretically at risk during the drilling of the scapula near the spinoglenoid notch. The purpose of this study was to assess the relationship between the screw securing the coracoid transfer and the SSN during open Trillat Procedure and define a safe zone for the SSN. METHODS: In this anatomical study, an open Trillat Procedure was performed on ten shoulders specimens. The coracoid was fixed by a screw after partial osteotomy and antero-posterior drilling of the scapular neck. The SSN was dissected with identification of the screw. We measured the distances SSN-screw (distance 1) and SSN-glenoid rim (distance 2). In axial plane, we measured the angles between the glenoid plane and the screw (α angle) and between the glenoid plane and the SSN (ß angle). RESULTS: The mean distance SSN-screw was 8.8 mm +/-5.4 (0-15). Mean α angle was 11°+/-2.4 (8-15). Mean ß angle was 22°+/-6.7 (12-30). No macroscopic lesion of the SSN was recorded but in 20% (2 cases), the screw was in contact with the nerve. In both cases, the ß angle was measured at 12°. CONCLUSION: During the open Trillat Procedure, the SSN can be injured due to its anatomical location. Placement of the screw should be within 10° of the glenoid plane to minimize the risk of SSN injury and could require the use of a specific guide or arthroscopic-assisted surgery.

Differences in Osseous Shoulder Morphology, Scapulothoracic Orientation, and Muscle Volume in Patients With Constitutional Static Posterior Shoulder Instability (Type C1) Compared With Healthy Controls.

BACKGROUND: Constitutional static posterior humeral decentering (type C1 according to ABC Classification) has been recognized as a pre-osteoarthritic deformity that may lead to early-onset posterior decentering osteoarthritis at a young age. Therefore, it is important to identify possible associations of this pathologic shoulder condition to find more effective treatment options. PURPOSE: To perform a comprehensive analysis of all parameters reported to be associated with a C1 shoulder-including the osseous shoulder morphology, scapulothoracic orientation, and the muscle volume of the shoulder girdle in a single patient cohort. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A retrospective, comparative study was conducted analyzing 17 C1 shoulders in 10 patients who underwent magnetic resonance imaging (MRI) with the complete depiction of the trunk from the base of the skull to the iliac crest, including both humeri. The mean age of the patients was 33.5 years, and all patients were men. To measure and compare the osseous shoulder morphology (glenoid version, glenoid offset, humeral torsion, anterior acromial coverage, posterior acromial coverage, posterior acromial height, and posterior acromial tilt) and scapulothoracic orientation (scapular protraction, scapular internal rotation, scapular upward rotation, scapular translation, scapular tilt, and thoracic kyphosis), these patients were matched 1 to 4 according their age, sex, and affected side with shoulder-healthy patients who had received positron emission tomography (PET)-computed tomography. To measure and compare the muscle volume of the shoulder girdle (subscapularis, infraspinatus/teres minor, supraspinatus, trapezius, deltoid, latissimus dorsi/teres major, pectoralis major, and pectoralis minor), patients were matched 1 to 2 with patients who had received PET-MRI. Patients with visible pathologies of the upper extremities were excluded. RESULTS: The C1 group had a significantly higher glenoid retroversion, increased anterior glenoid offset, reduced humeral retrotorsion, increased anterior acromial coverage, reduced posterior acromial coverage, increased posterior acromial height, and increased posterior acromial tilt compared with controls (P < .05). Decreased humeral retrotorsion showed significant correlation with higher glenoid retroversion (r = -0.742; P < .001) and higher anterior glenoid offset (r = -0.757; P < .001). Significant differences were found regarding less scapular upward rotation, less scapular tilt, and less thoracic kyphosis in the C1 group (P < .05). The muscle volume of the trapezius and deltoid was significantly higher in the C1 group (P < .05). CONCLUSION: Patients with C1 shoulders differ from healthy controls regarding osseous scapular and humeral morphology, scapulothoracic orientation, and shoulder girdle muscle distribution. These differences may be crucial in understanding the delicate balance of glenohumeral centering.

Treatment options and outcomes for delayed scapular anatomical neck fractures: a case report and review of the literature.

INTRODUCTION: Scapular anatomical neck fractures are among the most infrequent shoulder girdle fractures. Only seven radiologically confirmed cases of scapular anatomical neck fractures have been documented in the literature to date, of which only one case underwent delayed surgery. CASE PRESENTATION: A 34-year-old male Persian patient with morbid obesity was diagnosed with a scapula anatomical neck fracture after a motor vehicle collision. The radiographic assessment of the patient indicated an increase in the scapular glenopolar angle (73.9°). Due to concurrent chest and head injuries, surgical intervention was deferred until 6 weeks following the injury. The posterolateral limited Dupont-Evrard approach was used because of the patient's extremely high body mass index. Two plates were utilized to achieve stable fixation of the glenoid neck fracture. Following a 1 year follow-up period, complete fracture union was successfully attained, resulting in a constant score of 79. CONCLUSIONS: The most accurate radiographic indicators of these fractures are a superior fracture line located laterally to the coracoid process, a small inferior spike, and an elevated glenopolar angle. The only tendon attached to the glenoid is the long head of the triceps, making these fractures unstable; therefore, surgery is required in the majority of instances. The small size of the fractured component makes stabilization more difficult. Overall, anatomical scapular neck fractures are extremely uncommon and distinguished from other scapular fractures by their unique radiological and biomechanical characteristics. This case highlights the challenges encountered when managing scapular fractures in patients with morbid obesity. The delayed surgical intervention and the choice of surgical approach tailored to the patient's specific anatomical and physiological considerations proved to be effective in achieving a favorable outcome.

Technical refinements of the scapular tip-free flap for mandibular reconstruction.

BACKGROUND: The use of scapular tip chimeric free flaps (STFFs) for reconstructing mandibular defects has recently become popular, but its utility relative to other bone-containing free flaps remains debatable. The aim of the report is to describe how technical modification of STFF impacted in its use for mandibular reconstruction also commenting results obtained in a unicentric series of patients. PATIENTS AND METHODS: Patients undergoing mandibular reconstruction using an STFF from January 1, 2014 to June 1, 2022 were retrospectively enrolled in this report. We collected data on chimeric flap type, bone management, vascular pedicles, and the final outcomes. In total, 31 patients (13 men and 18 women) with a mean age of 68 years were enrolled. According to the classification system of Urken, 15 patients had body defects, while 7 had ramus defects, another 7 had symphysis defects, and 2 had both ramus and bodily defects. STFF was always harvested working in two equips simultaneously, in supine position. Dissection included preparation of chimeric components of the flap as latissimus dorsi, serratus and scapular tip. After pedicle dissection scapular bone was cut basing on reconstructive needing with a rectangular (stick) shape including the border of the scapula. In cases of longer bone harvesting, circumflex pedicle was also included to perfuse the upper portion of the scapular border. In five cases, the STFF was harvested with only the scapular angle component, and was thus a composite osteomuscular flap; for the remaining 26 cases, a chimeric STFF was used. Circumflex pedicle was included for eight patients. Six of the seven patients with symphyseal defects underwent a single osteotomy. RESULTS: The average length of the harvested was 69.92 mm (maximum length = 104 mm). The average height of transplanted bone was 26.78 mm (maximum height = 44.2 mm). Mouth-opening was normal in 25 patients, limited in 6 patients, and severely impaired in no patients. The cosmetic results were rated as excellent by 20 patients, good by 8 patients, and poor by 3 patients. CONCLUSION: The STFF is an excellent option for mandibular reconstruction when other flaps are not available and for patients in poor general condition. Technical innovations here presented made possible to harvest long bone segments with accurate shape thanks to osteotomies if needed and with adequate soft tissues components of the chimeric flap, ensuring satisfactory functional and cosmetic results.

Efficacy and safety of the Latarjet procedure for the treatment of athletes with glenoid bone defects ≥ 20%: a single-arm meta-analysis.

BACKGROUND: The shoulder joint is the most commonly dislocated joint in the human body, and the recurrence rate exceeds 50% after nonsurgical treatment. Although surgical treatment reduces the recurrence rate, there is controversy regarding the optimal surgical approach. Previous studies suggest that the Latarjet procedure yields favourable outcomes for specific populations at risk of recurrence, such as competitive athletes with significant glenoid defects. However, most of the existing related research consists of nonrandomized controlled trials with small sample sizes, and there is a lack of strong evidence regarding the efficacy and safety of the Latarjet procedure. METHODS: The PubMed, Embase, Cochrane Library, and Web of Science databases were systematically searched. Athletes with ≥ 20% glenoid defects were selected for inclusion. The following data were extracted: general patient information, instability rates, return to sports (RTS) rates, imaging features (graft positioning rate and graft healing rate), functional assessments [Rowe score, Athletic Shoulder Outcome Scoring System(ASOSS), visual analogue scale (VAS), forward flexion function, and external rotation function], and complications. RESULTS: After excluding suspected duplicate cases, a total of 5 studies were included in this meta-analysis. The studies involved a total of 255 patients, including 237 males (93%) and 18 females (7%). The average age at the time of surgery was 25.4 ± 8.5 years. All the studies had a minimum follow-up period of 2 years, with an average follow-up time of 48.7 ± 18.9 months. The pooled rate of return to sport (RTS) was 94.3% (95% CI: 87.3%, 98.8%), and 86.1% (95% CI: 78.2%, 92.5%) of patients returned to their preoperative level of activity. The pooled redislocation rate was 1.1% (95% CI: 0%, 3.8%). Regarding the imaging results, the combined graft retention rate was 92.1% (95% CI: 88.1%, 95.5%), and the graft healing rate was 92.1% (95% CI: 88%, 95.4%). Postoperative functional evaluation revealed that the combined Rowe score, ASOSS score, and VAS score were 93.7 ± 6.5 points, 88.5 ± 4.4 points, and 1.1 ± 10 points, respectively. The forward flexion and external rotation angles were 170.9 ± 6.9 degrees and 65.6 ± 4.5 degrees, respectively. After excluding one study with unclear complications, the combined complication rate was 9.4% (95% CI: 1.0%, 23.6%). CONCLUSION: For athletes with shoulder instability and a total of ≥ 20% glenoid bone defects, the Latarjet procedure can achieve excellent functional outcomes, with the majority of patients returning to preoperative levels of sports activity. This procedure also leads to a low recurrence rate. Therefore, the Latarjet procedure has been proven to be a safe and effective treatment.

Safety and Early Results for Off-Label Use of Intranasal Calcitonin for Treatment of Nondisplaced Acromial and Scapular Spine Stress Fractures After Reverse Total Shoulder Arthroplasty.

Immobilization for acromial and scapular spine stress AU4fractures (AF/SSF) after reverse total shoulder arthroplasty (RSA) is associated with patient dissatisfaction. Our study reports the effects and safety of intranasal calcitonin alongside sling immobilization on pain and function in the treatment of AF/SSF after RSA. The treatment was regimented calcitonin (salmon) 200 unit/actuation nasal spray (1 spray/day) for 6 weeks with sling immobilization for 4 weeks. Each patient was monitored through blood work. Visual analog scale, American Shoulder and Elbow Surgeons score, and active range of motion were collected preoperatively, postoperatively, at presentation of AF/SSF, and after completion of calcitonin treatment. Two hundred eighty-two RSAs were performed by two board-certified orthopaedic surgeons, of which 18 patients sustained AF/SSF (6.4%). Ten patients met inclusion criteria (nine AFs and one SSF). After calcitonin treatment, patients demonstrated an average improvement of visual analog scale of 5.8 points, active range of motion of 46_, and American Shoulder and Elbow Surgeons score of 43.6 points at average 7.53 months after RSA. No medical complications were reported at 6-month follow-up after calcitonin treatment. The use of intranasal calcitonin was not associated withadverse events including no aberrations/signs of cancer at 6-month follow-up after administration. Calcitonin with sling immobilization markedly improved clinical and functional outcomes of patients with nondisplaced AF/SSF and may be considered by orthopaedic surgeons for symptom management.

Rotator cuff isometric exercises in combination with scapular muscle strengthening and stretching in individuals with rotator cuff tendinopathy: A multiple-subject case report.

BACKGROUND AND PURPOSE: To assess the effects of a rehabilitation protocol of rotator cuff (RC) isometrics coupled with traditional shoulder exercises on patient-rated outcomes, muscle strength, and electromyographic activity in individuals with RC tendinopathy. METHODS: Eleven individuals (8 women and 3 men, 37.9 ± 5.6 years) with RC tendinopathy performed isometric RC exercises in combination with scapular muscle stretching and strengthening for 6 weeks. Treatment effects were assessed with patient-rated pain and shoulder function, isometric muscle strength, electromyographic activity during arm elevation and internal and external shoulder rotation, and pain during arm elevation before and at the end of the first session, and after 6 weeks of intervention. RESULTS: There were improvements in pain and shoulder function, increased isometric muscle strength for arm elevation and internal rotation, increased muscle activity of the infraspinatus and serratus anterior, and reduced pain during arm elevation after 6 weeks of intervention. DISCUSSION: This case report showed improvements on pain and function, increases on isometric strength of the shoulder and on electromyographic activity of the serratus anterior and infraspinatus muscles, as well as decreases on pain during arm elevation, after a 6-week intervention of RC isometric exercises associated with scapular muscle stretching and strengthening in patients with RC tendinopathy.

Acute effect of scapular mobilization with associated myofascial release on butterfly performance: Randomized clinical trial.

INTRODUCTION: To evaluate the acute effect of scapular mobilization with associated myofascial release compared to scapular mobilization without myofascial release on butterfly stroke sports performance. DESIGN: Randomized clinical trial. METHOD: Pilot study that non-probabilistically convenience sampling that selected butterfly swimmers who were simply randomized into three groups to receive the standard protocol (scapular mobilization with release of the subscapularis muscle by the lateral edge of the scapula and rib cage detachment) in intervention group (IG), sham group (SG) (scapular mobilization without subscapularis muscle release and without rib cage detachment) or no intervention in control group (CG). We evaluated the stroke frequency, length, and average speed of 30 swimmers using the 8.15 Kinovea® motion analysis system. RESULTS: The findings showed that, compared to the CG and IG, the SG showed a significant reduction in mean velocity (p = 0.002; p = 0.02, respectively), stroke frequency (p = 0.002; p = 0.003, respectively), and stroke length (p = 0.01; p = 0.05, respectively). DISCUSSION: The results showed that manual therapy through scapular mobilization without associated myofascial release with detachment of the scapula from the rib cage worsened the swimming efficiency indicators even after 30 min of application of the technique. The limitations of the studies are related to the sample size, the risk of non-probabilistic contraction bias and the lack of blinding of the evaluators. Thus, the results of this study should be evaluated with caution.

Shoulder kinetic during pitching in baseball players with scapular dyskinesis.

INTRODUCTION: Shoulder injuries in baseball players cause excessive shoulder load during pitching and scapular dyskinesis (SD). However, the characteristics of pitching kinetics in the shoulder joint with SD are unclear. This study aimed to investigate the effect of SD on pitching kinetics in the shoulder joint of baseball players. METHOD: Seventy-two college and independent league baseball players participated in the study. The pitching motion was measured using an 18-camera motion-capture system. SD was classified into four types (I-IV) using the scapular dyskinesis test (SDT). The pitching kinetics data were analyzed. RESULTS: The agreement of SD in this study was 56/72 (77.8%). SD were classified into 31 abnormal group (type I-Ⅲ) and 25 control group (type Ⅳ). Three participants with measurement failure during the pitching motion analysis were excluded from the analysis. The abnormal group showed a larger maximum value of the glenohumeral normalized anterior joint force than the control group. CONCLUSIONS: These results suggest that an increase in GH anterior force during pitching causes an excessive increase in external rotation of the GH with an insufficient posterior tilt of the scapula with SD. Therefore, baseball pitching with SD may involve shoulder injuries owing to excessive shoulder load during pitching.

Transformation of the pectoral girdle in pennaraptorans: critical steps in the formation of the modern avian shoulder joint.

Important transformations of the pectoral girdle are related to the appearance of flight capabilities in the Dinosauria. Previous studies on this topic focused mainly on paravians yet recent data suggests flight evolved in dinosaurs several times, including at least once among non-avialan paravians. Thus, to fully explore the evolution of flight-related avian shoulder girdle characteristics, it is necessary to compare morphology more broadly. Here, we present information from pennaraptoran specimens preserving pectoral girdle elements, including all purportedly volant taxa, and extensively compare aspects of the shoulder joint. The results show that many pectoral girdle modifications appear during the evolution from basal pennaraptorans to paravians, including changes in the orientation of the coracoid body and the location of the articulation between the furcula and scapula. These modifications suggest a change in forelimb range of motion preceded the origin of flight in paravians. During the evolution of early avialans, additional flight adaptive transformations occur, such as the separation of the scapula and coracoid and reduction of the articular surface between these two bones, reduction in the angle between these two elements, and elongation of the coracoid. The diversity of coracoid morphologies and types of articulations joining the scapula-coracoid suggest that each early avialan lineage evolved these features in parallel as they independently evolved more refined flight capabilities. In early ornithothoracines, the orientation of the glenoid fossa and location of the acrocoracoid approaches the condition in extant birds, suggesting a greater range of motion in the flight stroke, which may represent the acquisition of improved powered flight capabilities, such as ground take-off. The formation of a new articulation between the coracoid and furcula in the Ornithuromorpha is the last step in the formation of an osseous triosseal canal, which may indicate the complete acquisition of the modern flight apparatus. These morphological transitions equipped birds with a greater range of motion, increased and more efficient muscular output and while at the same time transmitting the increased pressure being generated by ever more powerful flapping movements in such a way as to protect the organs. The driving factors and functional adaptations of many of these transitional morphologies are as yet unclear although ontogenetic transitions in forelimb function observed in extant birds provide an excellent framework through which we can explore the behavior of Mesozoic pennaraptorans.