Effects of Using a Special Weighted Vest on Muscle Activity around the Scapula during Knee Push-Up Plus in Healthy Subjects.

Muscle imbalances in the upper body can lead to ineffective movement patterns and potential injury. The purpose of this study was to investigate the muscle activity, impact, and muscle activation ratio of the serratus anterior (SA), upper trapezius (UT), lower trapezius (LT), and pectoralis major (PM) during the knee push-up plus (KPUP) exercise under various loads. METHOD: Electromyography assessed scapular muscle activity in 32 healthy adults (15 males, 17 females) during three KPUP variations. RESULTS: PM and UT showed no significant activity differences across loads, whereas SA and LT did. SA activity was significantly higher in the weighted KPUP (WKPUP) 3 kg than that in KPUP and WKPUP 1 kg. LT activity was also significantly higher in WKPUP 3 kg compared to KPUP and WKPUP 1 kg, with KPUP showing higher activity than WKPUP 1 kg. PM/SA ratios remained consistent across loads, while UT/LT ratios varied significantly, being notably lower at 3 kg compared to 0 kg and 1 kg. Similarly, UT/SA ratios differed significantly among loads, being notably lower at 3 kg and 1 kg compared to 0 kg. CONCLUSION: WKPUP with 3 kg demonstrated significantly higher SA and LT activity compared to KPUP and WKPUP 1 kg. The lowest UT/LT ratio was observed during the WKPUP 3 kg, suggesting its effectiveness for optimizing muscle activation balance during KPUP exercises. These findings may inform the development of exercise protocols aimed at improving scapular stabilization.

Reduced Clavicle Length Indicates the Severity of Scapular Misalignment in Obstetric Brachial Plexus Lesions.

(1) Background: Although most brachial plexus birth palsies show some spontaneous recovery, secondary operations are likely to follow. Accordingly, due to the loss of muscle innervation, the growth of the affected limb and the shoulder girdle is reduced. This is associated with pathological scapula positioning and rotation. The objective of this work was to clarify the relationship between length differences of the two clavicles and different types of scapular dyskinesia. (2) Methods: Twenty-five patients suffering from brachial plexus birth palsy were included in this retrospective study. There were eighteen female and seven male patients with a mean age of 10 years (2 to 23 years). CT scans of the thoracic cage, including both shoulder joints and both clavicles, were obtained preoperatively between 2010 and 2012. Radiographic measurements were taken of the axial plane and 3D reconstructions were produced. Functional evaluations of possible movement and scapular dyskinesia were performed. (3) Results: We found an increasing difference in the length of the clavicle (both in absolute and relative terms) in the children with more pronounced scapular dyskinesia. Additionally, with increasing clavicle length differences, the scapula was positioned in a deteriorated angle compared to the healthy side. Significant positive correlations were identified for the age and absolute difference of the clavicle length and the length and width of the scapula on the affected side. (4) Conclusion: Scapular dyskinesia, which is a common finding in brachial plexus birth palsy, is strongly related to reduced clavicle growth. Reduced clavicle length (which is a relatively easily examinable parameter) compared to the healthy side can be used to estimate the extent of scapular malpositioning on the thoracic cage. The extent and severity of scapular dyskinesia increases with augmented differences in the length of the clavicle.

Inertial Sensors and Pressure Pain Threshold to Evaluate People with Primary Adhesive Capsulitis: Comparison with Healthy Controls and Effects of a Physiotherapy Protocol.

Inertial sensors (IMUs) have been recently widely used in exercise and rehabilitation science as they can provide reliable quantitative measures of range of motion (RoM). Moreover, the pressure pain threshold (PPT) evaluation provides an objective measure of pain sensation in different body areas. The aim of this study was to evaluate the efficacy of physiotherapy treatment in people with adhesive capsulitis in terms of RoM and pain improvement measured by IMUs and the PPT. A combined prospective cohort/cross-sectional study was conducted. Nineteen individuals with adhesive capsulitis (10/19 females, 54 ± 8 years) and nineteen healthy controls (10/19 females, 51 ± 6 years) were evaluated for active glenohumeral joint RoM and PPT on shoulder body areas. Then, individuals with adhesive capsulitis were invited to 20 sessions of a physiotherapy protocol, and the assessments were repeated within 1 week from the last session. The range of motion in the flexion (p = 0.001) and abduction (p < 0.001) of the shoulder increased significantly after the physiotherapy protocol. Similarly, the PPT was found to increase significantly in all the assessed shoulder body areas, leading to no significant differences compared to the healthy controls. IMU and PPT assessments could be used to evaluate the efficacy of physical therapy in people with adhesive capsulitis.

Scapular dyskinesis and loss of cervical lordosis in myofascial pain syndrome and its effects on pain and posture disorders.

Objectives: This study aimed to evaluate scapular dyskinesia and loss of cervical lordosis in myofascial pain syndrome and its effects on pain and posture disorders. Patients and methods: In this cross-sectional study, 101 individuals (74 females, 27 males; mean age: 44.3±8.8 years; range, 25 to 60 years) with chronic neck pain were recruited between January 2021 and February 2021. Demographic and clinical data of the patients were recorded. Visual Analog Scale (VAS), posture evaluation form, the scapular dyskinesia test, the lateral scapular shift test, and Cobb's methods for cervical angle measurements were used in the evaluation of the patients. Results: In the study population, 52.25% of patients had loss of cervical lordosis, and 44.5% of patients had scapular dyskinesia. It was observed that the VAS activity score was significantly higher in individuals with loss of cervical lordosis, all VAS scores and pain duration were significantly higher in individuals with scapular dyskinesia (p<0.05). Shoulder elevation, rounded shoulder, forward head posture, and kyphosis were significantly higher in patients with scapular dyskinesia, while thoracic kyphosis was significantly higher in patients with both scapular dyskinesia and loss of cervical lordosis (p<0.05). The presence of trigger points was found to be significantly higher in patients with scapular dyskinesia and in patients with both scapular dyskinesia and loss of cervical lordosis (p<0.05). Conclusion: In patients with chronic neck pain diagnosed with myofascial pain syndrome, the presence of loss of cervical lordosis and scapular dyskinesia have negative effects on pain and posture.

Arthroscopic scapulothoracic bursectomy with and without superomedial angle scapuloplasty: a comparison of patient-reported outcomes.

BACKGROUND: Operative treatment of scapulothoracic bursitis most commonly comprises arthroscopic scapulothoracic bursectomy with or without partial superomedial angle scapuloplasty. There is currently no consensus regarding whether or when scapuloplasty should be performed. Prior studies are limited to small case series, and optimal surgical indications are not yet established. The purposes of this study were (1) to retrospectively review patient-reported outcomes of arthroscopic treatment of scapulothoracic bursitis and (2) to compare outcomes between scapulothoracic bursectomy alone and bursectomy with scapuloplasty. We hypothesized that bursectomy with scapuloplasty would provide superior pain relief and functional improvement. MATERIALS AND METHODS: All cases of scapulothoracic débridement with or without scapuloplasty completed at a single academic center from 2007 through August 2020 were reviewed. Patient demographic characteristics, symptomatology data, physical examination findings, and corticosteroid injection response data were collected from the electronic medical record. Visual analog scale pain, American Shoulder and Elbow Surgeons, Simple Shoulder Test, and Single Assessment Numeric Evaluation scores were collected. Comparisons between the group undergoing bursectomy alone and the group undergoing bursectomy with scapuloplasty were made using the Student t test for continuous variables and the Fisher exact test for categorical variables. RESULTS: Thirty patients underwent scapulothoracic bursectomy alone, and 38 patients underwent bursectomy with scapuloplasty. Final follow-up data were available for 56 of 68 cases (82%). Final postoperative visual analog scale pain scores (3.4 ± 2.2 and 2.8 ± 2.2, respectively; P = .351), American Shoulder and Elbow Surgeons scores (75.8 ± 17.7 and 76.5 ± 22.5, respectively; P = .895), and Simple Shoulder Test scores (8.8 ± 2.3 and 9.5 ± 2.8, respectively; P = .340) were similar between the bursectomy-alone and bursectomy-with-scapuloplasty groups. CONCLUSION: Both arthroscopic scapulothoracic bursectomy alone and bursectomy with scapuloplasty are effective treatments for scapulothoracic bursitis. Operative time is shorter without scapuloplasty. In this retrospective series, these procedures showed similar outcomes regarding shoulder function, pain, surgical complications, and rates of subsequent shoulder surgery. Further studies with a focus on 3-dimensional scapular morphology may help optimize patient selection for each of these procedures.

Efficacy of Six Weeks Stability Exercises on the Glenohumeral Joint of Female Tennis Players with Scapular Dyskinesia.

Background: Stabilizing exercises reduce pain intensity, improves shoulder position and scapular function, and provides an appropriate strategy for the improvement of scapular dyskinesia. The purpose of this study was to investigate the effect of six weeks of stability exercises (stretching-strengthening) on joint proprioception, strength, and range of motion of the glenohumeral joint in female tennis players with scapular dyskinesia. Methods: Thirty-six female elite tennis players with scapular dyskinesia in both experimental and control groups participated in this study. Goniometer, Isokinetic and Biodex devices were used to evaluate the range of motion, internal and external rotation strength in 60° and 180°, and joint proprioception at 45° and 60°, respectively. Also, the lateral scapular slide test (LSST) was used to evaluate the scapulohumeral rhythm. For analyzing dependent variables and determining statistical significance the ANCOVA and an alpha of 5% was used. Results: The results of this study indicated the effect of the stability exercise program on the range of motion of internal (p = 0.016) and external (p = 0.023) rotation of the shoulder. Also, significant differences were observed between the control and training groups for internal rotation strength 60° (p = 0.013), 180° (p = 0.017) and external rotation strength 60° (p = 0.005), 180° (p = 0.045) and strength ratio 60° (p = 0.001) and 180° (p = 0.023). However, there were no significant differences for proprioception. Conclusion: In general, the findings of this study support the effectiveness of exercise therapy as a safe intervention for improving scapular function in tennis players with scapular dyskinesia.

Arthroscopic release of the pectoralis minor tendon as an adjunct to acromioplasty in the treatment of subacromial syndrome associated with scapular dyskinesia.

INTRODUCTION: One of the causes of scapular dyskinesia is the retraction of the pectoralis minor muscle. It can be the cause of shoulder pain associated with increased anterior tilt and internal rotation of the shoulder. HYPOTHESIS: Arthroscopic release of the pectoralis minor tendon is effective for shoulder pain, linked to a correction of dyskinesia, resulting in the early disappearance of scapulalgia. PATIENTS AND METHODS: This was a retrospective, monocentric, single-surgeon study on a continuous series of patients with symptomatic shoulder pain, related to subacromial impingement associated with scapular dyskinesia. The series underwent arthroscopic tenotomies of the pectoralis minor between January 2015 and September 2018. Fifty-eight releases were performed to 57 patients (22 males, 35 females), with a mean age of 51.4 years (29-66 years). In all cases, they presented pain on palpation of the upper bundle of the trapezius muscle, and on palpation of the coracoid insertion of the pectoralis minor. RESULTS: Preoperatively, there were 30 cases of stage 1 scapular dyskinesia and 28 cases of stage 2, with a scapular index measured at 53.84 (41.66-65.78), while the constant score was 41.46 (19-59). Upper trapezius pain was present in 87.7% of cases. The 57 patients were clinically assessed, with a mean follow-up of 8.9 months (6-24 months). Post-operatively, 15 cases (25.8%) of scapulalgia persisted at 2 months of follow-up, while upper trapezius pain was present in only 22.4%. Scapular dyskinesia was no longer present at 2 months in patients without scapulalgia. The scapular index was measured at 60.42 (52.38-70.96), and the constant score at last follow-up was 76.36 (42-92). CONCLUSION: Tenotomy of the pectoralis minor improves painful symptomatology and scapular dyskinesia, in cases of subacromial syndrome with retraction of the pectoralis minor muscle. LEVEL OF EVIDENCE: IV, retrospective study.

Alleged recurrent traumatic shoulder dislocation in a young male patient - Diagnostic and management considerations.

A young male presented to a nearby hospital with a left shoulder dislocation after an alleged kickboxing injury. The patient reported worrying clinical findings including excruciating pain and absent sensation distally. Reduction was successful but his shoulder re-dislocated shortly after. His reported symptoms worsened and he was transferred to our institution. Imaging findings were not immediately concerning and he went to theatre the next day for an examination under anaesthetic. His shoulder was re-located easily and an immobiliser applied. Less than an hour later, the patient managed to re-dislocate his shoulder in recovery. He was subjected to another general anaesthetic and successful reduction. He absconded the following day after being declined multiple and increasing doses of opioid analgesia. He re-presented three weeks later with similar clinical findings but a different mechanism of injury. Further exploration of his collateral history revealed that he had been using a false identity. He had presented to all hospitals in our city within the previous 6 months. Once confronted, he did not return to these hospitals. He was also capable of self-relocating his shoulder. This case bore a striking resemblance to a case described by Warren in 2000 of a young lady with an apparently dislocated shoulder presenting to multiple city hospitals looking for analgesia and general anaesthetics. We wished to highlight the diagnostic and ethical challenges associated with these patients. They are vulnerable and so a high index of clinical suspicion is needed on the part of the surgeon to avoid unnecessary interventions. Effective communication between orthopaedic departments is a key recommendation from this case to mitigate risk of harm to these patients.

Focus on the Scapular Region in the Rehabilitation of Chronic Neck Pain Is Effective in Improving the Symptoms: A Randomized Controlled Trial.

Chronic neck pain is a common human health problem. Changes in scapular posture and alteration of muscle activation patterns of scapulothoracic muscles are cited as potential risk factors for neck pain. The purpose of this study was to compare the effects of neck exercise training (NET) with and without scapular stabilization training (SST) on pain intensity, the scapula downward rotation index (SDRI), forward head angle (FHA) and neck range of motion (ROM) in patients with chronic neck pain and scapular dyskinesia. A total of sixty-six subjects with chronic neck pain and scapular dyskinesia were randomly divided into three groups: neck exercise training, n = 24, combined training (NET + SST), n = 24 and a control group, n = 24. Pain intensity, SDRI, FHA and ROM were measured by the numerical rating scale, caliper, photogrammetry and IMU sensor, respectively. When the combined intervention group consisting of NET and SST was compared with NET alone at six weeks, there was a statistically significant difference in pain intensity, SDRI, FHA and cervical ROM for flexion and extension (p ≤ 0.05). Adding scapular exercises to neck exercises had a more significant effect in decreasing pain intensity, SDRI, FHA and increased cervical ROM than neck exercises alone in patients with chronic neck pain. These findings indicate that focus on the scapular posture in the rehabilitation of chronic neck pain effectively improves the symptoms.

Heterogeneity among patients with subacromial pain - variabilities within clinical presentation and its impact on daily life.

OBJECTIVE: The primary aim was to describe the variability within clinical presentation of patients with subacromial pain in primary care, secondly to investigate associations between clinical presentation and self-reported pain intensity, shoulder function, level of anxiety and depression, and health-related quality of life. DESIGN AND SETTING: A cross-sectional study based on data from two clinical studies in primary care, one randomized controlled trial and one implementation study. Three components: active range of motion (AROM), rotator cuff function and scapular kinematics were analyzed to describe variability within clinical presentation and patient-reported measurements were used to investigate the impact on daily life. PARTICIPANTS: Patients aged 30-67 years, describing pain for more than two weeks, with positive signs for a minimum of three out of the following five clinical tests: impingement sign according to Neer, impingement test according to Hawkins-Kennedy, Pattes maneuver, Jobe's test, and painful arc. RESULTS: Among the 164 patients included, 24% displayed dysfunction in one, 50% two and 24% in all three components. Limited AROM was seen in 46%, rotator cuff dysfunction in 91% and scapular dyskinesia in 57% of the patients. CONCLUSIONS: These results reveal a heterogeneity among primary care patients with subacromial pain confirming a large variability regarding the components AROM, rotator cuff function and scapular kinematics. All three components appear unique (not significantly correlated) where a rotator cuff dysfunction is very frequent while limited AROM and scapular dyskinesia are more inconsistent. There are significant, but rather weak, associations between clinical presentation and impact on daily life.

A computer tablet software can quantify the deviation of scapula medial border from the thoracic wall during clinical assessment of scapula dyskinesis.

PURPOSE: Aim of this study is to establish an objective and easily applicable method that will allow clinicians to quantitatively assess scapular dyskinesis during clinical examination using a computer tablet software. Hypothesis is that dyskinetic scapulae present greater motion-deviation from the thoracic wall-compared to the non-dyskinetic ones and that the software will be able to record those differences. METHODS: Twenty-five patients and 19 healthy individuals were clinically evaluated for the presence of dyskinesis or not. According to the clinical diagnosis, the observations were divided into three groups; A. Dyskinetic scapulae with symptoms (n = 25), B. Contralateral non-dyskinetic scapulae without symptoms (n = 25), C. Healthy control scapulae (n = 38). Then, all individuals were tested using a tablet with the PIVOT™ image-based analysis software (PIVOT, Impellia, Pittsburgh, PA, USA). The motion produced by the scapula medial border and inferior angle deviation from the thoracic wall was recorded. RESULTS: The deviation of the medial border and inferior angle of the scapula from the thoracic wall was 24.6 ± 7.3 mm in Group A, 14.7 ± 4.9 mm in Group B, and 12.4 ± 5.2 mm in Group C. The motion recorded in the dyskinetic scapulae group was significantly greater than both the contralateral non-dyskinetic scapulae group (p < 0.01) and the healthy control scapulae group (p < 0.01). CONCLUSION: The PIVOT™ software was efficient to detect significant differences in the motion between dyskinetic and non-dyskinetic scapulae. This system can support the clinical diagnosis of dyskinesis with a numeric value, which not only contributes to scapula dyskinesis grading but also to the evaluation of the progress and efficacy of the applied treatment, thus providing a feedback to the clinician and the patient. LEVEL OF EVIDENCE: IV, laboratory study.

Decreased external rotation strength is a risk factor for overuse shoulder injury in youth elite handball athletes.

PURPOSE: Overuse shoulder injuries are common in youth handball, but research is limited. The purpose of this study was to identify pre-season risk factors associated with overuse shoulder injuries in this population. METHODS: One-hundred and thirty-eight (70 boys and 68 girls) youth elite players (age 14.1 ± 0.8 years, height 175.2 ± 8.2 cm, weight 64.0 ± 9.6 kg) completed a pre-season screening protocol. Passive glenohumeral range of motion and maximum external (ER) and internal rotation (IR) strength were measured with a manual goniometer and a hand-held dynamometer. Scapular dyskinesia and maximum throwing velocity were also assessed. Players completed standardised questionnaires over the 2017-2018 season and reported any overuse shoulder symptoms. RESULTS: Decreased isometric and eccentric ER strength was identified as a risk factor for overuse shoulder injury, both for absolute (OR 10.70, 95% CI 1.2-95.6, p = 0.034) and normalised ER strength (OR 1.2, 95% CI 1.0-1.4, p = 0.015) and the ER:IR strength ratio (OR 1.2, 95% CI 1.1-1.5, p = 0.012). ER gain of more than 7.5° (p = 0.025) and GIRD of more than 7.5° (p = 0.014) were identified as risk factors for overuse shoulder injury in girls. Scapular dyskinesia (OR 1.1, n.s.) and maximum throwing velocity did not seem to contribute to injury risk. The average response rate was 63%. CONCLUSION: In elite youth handball, deficits in ER strength is a risk factor for overuse shoulder injury for both sexes; ER gain and GIRD are only risk factors for girls. Focused pre-season assessments may aid the identification of risk factors for shoulder overuse injuries and the application of specific programmes to reduce risk. LEVEL OF EVIDENCE: II.

NA-CONTROL: a study protocol for a randomised controlled trial to compare specific outpatient rehabilitation that targets cerebral mechanisms through relearning motor control and uses self-management strategies to improve functional capability of the upper extremity, to usual care in patients with neuralgic amyotrophy.

BACKGROUND: Neuralgic amyotrophy (NA) is a distinct peripheral neurological disorder of the brachial plexus with a yearly incidence of 1/1000, which is characterised by acute severe upper extremity pain. Weakness of the stabilising shoulder muscles in the acute phase leads to compensatory strategies and abnormal motor control of the shoulder - scapular dyskinesia. Despite peripheral nerve recovery, scapular dyskinesia often persists, leading to debilitating residual complaints including pain and fatigue. Evidence suggests that persistent scapular dyskinesia in NA may result from maladaptive cerebral neuroplasticity, altering motor planning. Currently there is no proven effective causative treatment for the residual symptoms in NA. Moreover, the role of cerebral mechanisms in persistent scapular dyskinesia remains unclear. METHODS: NA-CONTROL is a single-centre, randomised controlled trial comparing specific rehabilitation to usual care in NA. The rehabilitation programme combines relearning of motor control, targeting cerebral mechanisms, with self-management strategies. Fifty patients will be included. Patients are recruited through the Radboud university medical center Nijmegen, the Netherlands. Patients with a (suspected) diagnosis of NA, with lateralized symptoms and scapular dyskinesia in the right upper extremity, who are 18 years or older and not in the acute phase can be included. The primary outcome is the Shoulder Rating Questionnaire score, which measures functional capability of the upper extremity. Secondary clinical outcomes include measures of pain, fatigue, participation, reachable workspace, muscle strength and quality of life. In addition, motor planning is assessed with first-person motor imagery and functional magnetic resonance imaging. In a sub-study the patients are compared to 25 healthy participants, to determine the involvement of cerebral mechanisms. This will enable interpretation of cerebral changes associated with the rehabilitation programme and functional impairments in NA. DISCUSSION: NA-CONTROL is the first randomised trial to investigate the effect of specific rehabilitation on residual complaints in NA. It also is the first study into the cerebral mechanisms that might underlie persistent scapular dyskinesia in NA. It thus may aid the further development of mechanism-based interventions for disturbed motor control in NA and in other peripheral neurological disorders. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03441347 . Registered on 20 February 2018.

A comparison of physical characteristics, functions and quality of life between breast cancer survivor women who had a mastectomy and healthy women.

BACKGROUND: The quality of life of breast cancer survivors who had a mastectomy may decrease due to potential physical problems and reduced upper extremity functions. OBJECTIVE: This study aimed to compare the physical characteristics, upper extremity functions and quality of life of breast cancer survivors and healthy women. METHODS: A total of 66 women participated in this study: breast cancer survivors (n= 33) and healthy counterparts (n= 33) participated in this study. The Lateral Scapular Dyskinesia Slide Test was used to evaluate scapular dyskinesia, the hand-held dynamometer was used to measure upper extremity muscular strength, the Angle Reproduction Test was used to measure upper extremity position sense, the Disabilities of the Arm, Shoulder and Hand questionnaire was used to assess upper extremity functions, and the Short Form-36 was used to assess the quality of life. RESULTS: The findings showed that the prevalence of scapular dyskinesia was higher, whereas upper extremity muscle strength, shoulder joint position sense, upper extremity functions and many sub-dimensions of quality of life were reduced in breast cancer survivor women compared to the healthy women (p< 0.05). CONCLUSIONS: Several physical characteristics, upper extremity functions and quality of life of breast cancer survivor women who had a mastectomy were affected more in comparison to healthy women. Thus, these parameters should be included in physiotherapy assessment and treatment programs.

Comparison of scapular position and upper extremity muscle strength in patients with and without lateral epicondylalgia: a case-control study.

BACKGROUND: The symptoms of lateral epicondylalgia (LE) can be persistent, and recurrence is frequent. Recurrence can be related to proximal segment impairment of the kinetic chain. Knowledge of any relation in the kinetic chain in LE may help treatment. We aimed to investigate scapular position and upper extremity muscle strength in patients with LE and to compare them with controls. METHODS: The study enrolled 51 patients with LE and 51 age-matched controls. We assessed scapular position asymmetry using the lateral scapular slide test and measured the strength of the upper trapezius (UT), middle trapezius (MT), lower trapezius, and serratus anterior muscles in addition to shoulder abduction, external rotation, and internal rotation and grip strength. RESULTS: The percentage of participants with scapular asymmetry was greater in the patients than in the controls (P = .005). The involved side regarding shoulder external rotation among the patients was significantly weaker than in the controls (P = .016, P = .009). The involved side of the LE patients was significantly weaker than the uninvolved side in terms of shoulder abduction, external rotation, and internal rotation (P = .013, P = .048, P = .013). The UT/MT ratio on the nondominant side of the controls was significantly greater than that on the involved side of the LE patients (P = .016). CONCLUSION: Upper extremity muscle strength, grip strength, UT/MT ratio, and scapular position are affected in patients with LE. In addition to the elbow, focusing on the upper segments is essential in the management of LE.

Multidirectional Instability: Natural History and Evaluation.

BACKGROUND: Multidirectional instability (MDI) represents a great challenge to the orthopedic surgeon. When treating these patients we must be aware that instability refers to a symptomatic situation, thus multidirectional instability is defined as symptomatic involuntary instability in two or more directions, and should be clearly differentiated from asymptomatic hyperlaxity. It may be associated with hyperlaxity, either congenital or acquired following repetitive stress, but also may be present without hyperlaxity, which is rare. METHODS: We searched in the online data bases and reviewed the relevant published literature available. RESULTS: Many differences can be seen in the current literature when identifying these patients, unclear definitions and criteria to be included in this patient group are common. CONCLUSION: Understanding the complex shoulder biomechanics as well as being aware of the typical clinical features and the key examination signs, which we review in this article, is of paramount importance in order to identify and classify these patients, allowing the best treatment option to be offered to each patient.

Surgical Release of the Pectoralis Minor Tendon for Scapular Dyskinesia and Shoulder Pain.

BACKGROUND: Pectoralis minor (PM) tightness has been linked to pain and dysfunction of the shoulder joint secondary to anterior tilt and internal rotation of the scapula, thus causing secondary impingement of the subacromial space. PURPOSE: To describe outcomes pertaining to nonoperative and operative treatment via surgical release of the PM tendon for pathologic PM tightness in an active population. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Over a 3-year period, a total of 46 patients were enrolled (mean age, 25.5 years; range, 18-33 years). Inclusion criteria consisted of symptomatic shoulder pain, limited range of overhead motion, inability to participate in overhead lifting activities, and examination findings consistent with scapular dysfunction secondary to a tight PM with tenderness to palpation of the PM tendon. All patients underwent a lengthy physical therapy and stretching program (mean, 11.4 months; range, 3-23 months), which was followed by serial examinations for resolution of symptoms and scapular tilt. Of the 46 patients, 6 (13%) were unable to adequately stretch the PM and underwent isolated mini-open PM release. Outcomes were assessed with scapula protraction measurements and pain scales as well as American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and visual analog scale (VAS) scores. RESULTS: Forty of the 46 patients (87%) resolved the tight PM and scapular-mediated symptoms with a dedicated therapy program (pre- and posttreatment mean outcome scores: 58 and 91 [ASES], 50 and 90 [SANE], 4.9 and 0.8 [VAS]; P < .01 for all), but 6 patients were considered nonresponders (mean score, 48 [ASES], 40 [SANE], 5.9 [VAS]) and elected to have surgical PM release, with improved scores in all domains (mean score, 89 [ASES], 90.4 [SANE], 0.9 [VAS]; P < .01) at final follow-up of 26 months (range, 25-30 months). Additionally, protraction of the scapula improved from 1.2 to 0.3 cm in a mean midline measurement from the chest wall preoperatively to postoperatively ( P < .01), similar to results in nonoperative responders. No surgical complications were reported, and all patients returned to full activities. CONCLUSION: In most patients, PM tightness can be successfully treated with a nonoperative focused PM stretching program. However, in refractory and pathologically tight PM cases, this series demonstrates predictable return to function with notable improvement in shoulder symptoms after surgical release of the PM. Additional research is necessary to evaluate the long-term efficacy of isolated PM treatment.

Assessment of cervical range of motion, cervical core strength and scapular dyskinesia in violin players.

BACKGROUND: Playing the violin can lead to asymmetric postures which can affect the cervical range of motion, cervical core strength and scapular stability. OBJECTIVE: The objective of the study was to assess the cervical range of motion, cervical core strength and scapular dyskinesia in violin players and non-players of the same age group. METHODS: An inclinometer was used to assess the cervical range of motion, pressure biofeedback was used to assess cervical core strength and scapular dyskinesia was also assessed in 30 professional violin players (18-40 years) compared with 30 age-matched non-players. Analysis was done using an unpaired t test. RESULTS: Significant change was seen with respect to extension (p = 0.051), cervical core strength (p = 0.005), right (Rt) superior angle 0° (p = 0.004), Rt superior angle 45° (p = 0.015) and Rt inferior angle 90° (p = 0.013). CONCLUSION: This study shows a significant difference in extension range of motion and cervical core strength of violin players. Also, there was scapular dyskinesia seen at 0° and 45° right-side superior angle of the scapula and 90° right-side inferior angle of the scapula.