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A 35-year-old Chinese man with no risk factors for stroke presented with a 2-day history of expressive dysphasia and a 1-day history of right-sided weakness. The presentation was preceded by multiple sessions of neck, shoulder girdle and upper back massage for pain relief in the prior 2 weeks. CT of the brain demonstrated an acute left middle cerebral artery infarct and left internal carotid artery dissection. MRI cerebral angiogram confirmed left carotid arterial dissection and intimal oedema of bilateral vertebral arteries. In the absence of other vascular comorbidities and risk factors, massage-induced internal carotid arterial dissection will most likely precipitate the near-fatal cerebrovascular event. The differential diagnosis of stroke in a younger population was consequently reviewed and discussed.

Context: Lumbopelvic-hip complex (LPHC) exercises are used to increase stabilization within the human body. Torso-elevated side support (TESS), foot-elevated side support (FESS), prone bridge plank (PBP), and V-sit are common LPHC exercises. Objective: To evaluate muscle activation in the shoulder girdle and LPHC during 4 LPHC exercises and evaluate the reasoning for termination. Study Design: Cross-sectional study. Setting: Laboratory. Patients or Other Participants: Seventeen healthy participants (12 males and 5 females; age: 21.47 [3.16] y, height: 179.73 [8.92] cm, mass: 76.89 [11.17] kg). Main Outcome Measures: Participants completed 2 repetitions of the TESS, FESS, PBP, and V-sit until failure. Surface electromyography of the middle deltoid, latissimus dorsi, middle trapezius, rectus abdominis, erector spinae, external oblique, and gluteus medius were recorded and normalized to maximum voluntary isometric contraction (MVIC). The duration of exercise and subjective reasoning for termination of exercise was completed following the 4 tasks. Results: The TESS and PBP had significantly greater middle deltoid muscle activation (TESS: 55.66% [24.45%] MVIC and PBP: 42.63% [18.25%] MVIC) compared with the FESS (10.10% [10.04%] MVIC) and V-sit (2.21% [1.94%] MVIC), P P Conclusions: The V-sit resulted in isolated activity of the abdominal portion of the LPHC. The FESS had increased global co-contraction of the LPHC compared with the TESS. The PBP and TESS had significant muscle activation in the upper-extremity.

The functions of the subclavius muscle (SM) are described as stabilization of the sternoclavicular joint (SCJ) and resisting elevation of the lateral end of the clavicle. During systematic cadaveric dissections, we observed additional fibrous structures, previously described as variants of the anatomy, extending from the SM and inserting into the coracoid process (CP). Due to the high incidence of these structures in our dissections, we hypothesized that the attachment at the CP is more common than appreciated and that, as a corollary, the function of the SM was (or has been) more complex than simply depressing the clavicle and generating stability at the SCJ. For our investigation, fifty‐two upper extremities of 26 human cadavers were dissected. The SM was demonstrated from costal to clavicular attachment. We documented additional fibrous structures apparently derived from the SM inserting into the CP. Measurements of the length of the SM, the length of its attachment, and the length of the clavicle were taken in situ, with the specimens supine and the upper extremity in the anatomical position. Variations in the anatomy of the SM and its coracoidal attachment were recorded, and potential correlations were investigated. For documentation purposes photographs and video sequences of passive motion of the shoulder girdle of the specimens were taken. In 49 of the 52 specimens we found additional fibrous structures passing from the SM to the CP. We differentiated three types: (1) a strong cord‐like structure; (2) a small or thin cord‐like structure or structures; and (3) a planar twisted sheet‐like structure. The SM and its extension to the CP appears to contribute to a ‘functional scapular suspension system’ together with the other muscles enveloped by the clavipectoral fascia (pectoralis minor, coracobrachialis and the short head of the biceps brachii). This system assists in the control of the position of the scapula in relation to the thorax, particularly in elevated positions of the upper extremity. We speculate that the differentiation of the fibrous structure depends on the functional demands of the individual. Level of Evidence: Basic science study., Dissections of the upper extremity showed a fibrous structure, extending from the subclavius muscle (SM) and inserting into the coracoid process. Due to the high incidence, we hypothesized that this structure is more common than appreciated and that the function of the SM was (or has been) more complex.

Brachial plexus injury (BPI) occurs when the brachial plexus is compressed, stretched, or avulsed. Although rodents are commonly used to study BPI, these models poorly mimic human BPI due to the discrepancy in size. The objective of this study was to compare the brachial plexus between human and Wisconsin Miniature SwineTM (WMSTM ), which are approximately the weight of an average human (68-91 kg), to determine if swine would be a suitable model for studying BPI mechanisms and treatments. To analyze the gross anatomy, WMS brachial plexuses were dissected both anteriorly and posteriorly. For histological analysis, sections from various nerves of human and WMS brachial plexuses were fixed in 2.5% glutaraldehyde, and postfixed with 2% osmium tetroxide. Subsequently paraffin sections were counter-stained with Masson's Trichrome. Gross anatomy revealed that the separation into three trunks and three cords is significantly less developed in the swine than in human. In swine, it takes the form of upper, middle, and lower systems with ventral and dorsal components. Histological evaluation of selected nerves revealed differences in nerve trunk diameters and the number of myelinated axons in the two species. The WMS had significantly fewer myelinated axons than humans in median (p = 0.0049), ulnar (p = 0.0002), and musculocutaneous nerves (p = 0.0454). The higher number of myelinated axons in these nerves for humans is expected because there is a high demand of fine motor and sensory functions in the human hand. Due to the stronger shoulder girdle muscles in WMS, the WMS suprascapular and axillary nerves were larger than in human. Overall, the WMS brachial plexus is similar in size and origin to human making them a very good model to study BPI. Future studies analyzing the effects of BPI in WMS should be conducted.

T1-weighted, cross-sectional MR images showing shoulder girdle, abdominal, paraspinal, gluteal and thigh muscles almost completely replaced by fat, whereas lower leg muscles are almost unaffected i a patient who is compound heterozygous for pathogenic variants in GOSR2.

Background Approximately 9% of shoulder girdle injuries involve the acromioclavicular joint (ACJ). There is no clear gold standard or consensus on surgical management of these injuries, in part perpetuated by our incomplete understanding of native ACJ biomechanics. We have therefore conducted a biomechanical study to assess the stabilizing structures of the ACJ in superior-inferior (SI) translation and anterior-posterior (AP) translation. Methods Twenty fresh frozen cadaveric specimens were prepared and mounted onto a robotic arm. The intact native joint was tested in SI translation and AP translation under a 50-N displacing force. Each specimen was retested after sectioning of its stabilizing structures in the following order: investing fascia, ACJ capsular ligaments, trapezoid ligament, and conoid ligament. Their contributions to resisting ACJ displacements were calculated. Results In the intact native ACJ, mean anterior displacement of the clavicle was 7.9 ± 4.3 mm, mean posterior displacement was 7.2 ± 2.6 mm, mean superior displacement was 5.8 ± 3.0 mm, and mean inferior displacement was 3.6 ± 2.6 mm. The conoid ligament was the primary stabilizer of superior displacement (45.6%). The ACJ capsular ligament was the primary stabilizer of inferior displacement (33.8%). The capsular ligament and conoid ligament contributed equally to anterior stability, with rates of 23% and 25.2%, respectively. The capsular ligament was the primary contributor to posterior stability (38.4%). Conclusion The conoid ligament is the primary stabilizer of superior displacement of the clavicle at the ACJ and contributes significantly to AP stability. Consideration should be given to reconstruction of the ACJ capsular ligament for complete AP stability in high-grade and horizontally unstable ACJ injuries.

OBJECTIVE We sought to determine if white-light three-dimensional (3D) body scanning can identify clinically relevant shoulder girdle deformity after displaced diaphyseal clavicle fracture (DCF). METHODS Adult patients with DCF (OTA/AO 15A) were prospectively enrolled. Four subcutaneous osseous landmarks were used to measure shoulder girdle morphology of the injured and uninjured shoulder. Measurements were made both manually with a tape measure and digitally with a white-light 3D scanner. Bilateral radiographs were obtained, and clavicle length was recorded. Quick-Disabilities of the Arm, Shoulder, and Hand surveys were administered at injury and at 6 and 12 weeks. RESULTS Twenty-two patients were included in the study. At the initial visit, all patients had significant differences in deformity measurements between injured and uninjured shoulders as measured by 3D scanning. There was no difference between shoulders measured using manual measurements. At 6 and 12 weeks, shoulder asymmetry was significantly less in patients treated with surgery compared with nonoperative patients as measured by the 3D scanner alone. Clavicle shortening measured on 3D scanning had weak and moderate positive correlations to radiographs (R = 0.27) and manual measurements (R = 0.53), respectively. Patients treated with surgery had significant functional improvements by 6 weeks, and a similar improvement was not seen until 12 weeks in nonsurgical patients. CONCLUSION White-light 3D scanning was able to identify and monitor clinically relevant shoulder girdle deformity after DCF. This tool may become a useful adjunct to clinical examination and radiographic assessment, when determining clinically relevant deformity thresholds. In the future, quantifying and understanding shoulder deformity may inform clinical decision making in these patients. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background Extra-abdominal desmoid tumor fibromatosis (DTF) is a rare, locally aggressive soft tissue tumour. The best treatment modality for this patient cohort is still object of debate. Questions/purpose This paper aimed to (1) to compare the outcomes of DTF after different treatment modalities, (2) to assess prognostic factors for recurrence following surgical excision, and (3) to assess prognostic factors for progression during observation. Methods This was a retrospective multicenter study under the patronage of the European Musculoskeletal Oncology Society (EMSOS). All seven centres involved were tertiary referral centres for soft tissue tumours. Baseline demographic data was collected for all patients as well as data on the diagnosis, tumour characteristics, clinical features, treatment modalities and whether they had any predisposing factors for DTF. Results Three hundred eighty-eight patients (240 female, 140 male) with a mean age of 37.6 (±18.8 SD, range: 3–85) were included in the study. Two hundred fifty-seven patients (66%) underwent surgical excision of ADF, 70 patients (18%) were observed without therapy, the residual patients had different conservative treatments. There were no significant differences in terms of tumour recurrence or progression between the different treatment groups. After surgical excision, younger age, recurrent disease and larger tumour size were risk factors for recurrence, while tumours around the shoulder girdle and painful lesions were at risk of progression in the observational group. Conclusion Local recurrence rate after surgery was similar to progression rates under observation. Hence, observation in DTF seems to be justified, considering surgery in case of dimensional progression in 2 consecutive controls (3 and 6 months) and in painful lesions, with particular attention to lesions around the shoulder girdle.

Several articular, muscular and neurological diseases generate mobility loss in the shoulder and pelvis girdles. Joint mobilization contributes to improving shoulder-pelvis girdles dissociation, but current mobilization techniques are not always successful and standardized. A robotic medical device, DPA Med®, by inducing trunk mobilization through lower limb oscillation has been developed for producing such a shoulder-pelvis girdles dissociation and is already used worldwide in rehabilitation hospitals.To determine the optimal lower limb oscillation frequency that generated the best shoulder-pelvis girdles dissociation using the DPA Med® device.Thirty healthy adult volunteers (mean age: 38.6 [SD 15.2] years, mean height: 174 [SD 11.9] cm, mean body mass: 70.3 [SD 14.7] kg) participated in this prospective study. A kinematic analysis quantified pelvic and shoulder girdle mobility (rotation and lateral tilt) at different DPA Med® frequencies, from 0.5 Hz to 1 Hz. A visual analysis of the lower limb movement was also performed, using video sensors, to better understand the kinematics involved.All DPA Med® frequencies have shown significant shoulder-pelvis girdles dissociation (p 0.05). This study established an optimal oscillation frequency with the minimal interindividual variability at 0.808 Hz. It induced pelvic mobility similar to that of normal gait, in the transverse and frontal planes (10.3°, SD 2.9°, and 12.0°, SD 2.2°, respectively). This trunk mobility was achieved by producing a lemniscate-shaped motion in the lower limbs (an eight-shaped motion in the transverse plane).This study has shown that the DPA Med® device is able to induce shoulder-pelvis girdles dissociation similar to that of normal gait and allowed to establish the existence of an optimal DPA Med® oscillation frequency for lower limb mobility at 0.808 Hz. Further studies are required to evaluate its potentially benefits on gait disorders.

Purpose The purpose of this case is to describe an exercise program designed for an individual with athetoid cerebral palsy who had difficulties with fine motor control and shoulder girdle stability. Summary of key points ET is a 19-year-old man with dyskinetic-type cerebral palsy with rapidly fluctuating muscle tone and movements that preclude trunk and extremity control necessary for the effective performance of functional activities. The participant underwent a 6-week intense physical therapy program aimed at strength and stability at the shoulder girdle and fine motor movements of the hand. Conclusions ET had improvements on the Performance of Upper Limb Scale, myometry, and from family report after 6 weeks. Recommendations A progressive exercise program aimed at improving proximal stability and fine motor function might be an appropriate intervention for persons with athetoid cerebral palsy. Video abstract For more insights from the authors, see Supplemental Digital Content 1, available at: http://links.lww.com/PPT/A315.

BACKGROUND: Abnormal movement patterns due to compensatory mechanisms have been reported in patients with rotator cuff tears. The long head of the biceps tendon may especially be overactive and a source of pain and could induce abnormal muscle activation in these patients. It is still unknown why some patients with a rotator cuff tear develop complaints and others do not.QUESTIONS/PURPOSES: (1) Which shoulder muscles show a different activation pattern on electromyography (EMG) while performing the Functional Impairment Test-Hand and Neck/Shoulder/Arm (FIT-HaNSA) in patients with a symptomatic rotator cuff tear compared with age-matched controls with an intact rotator cuff tear? (2) Which shoulder muscles are coactivated on EMG while performing the FIT-HaNSA?METHODS: This comparative study included two groups of people aged 50 years and older: a group of patients with chronic symptomatic rotator cuff tears (confirmed by MRI or ultrasound with the exclusion of Patte stage 3 and massive rotator cuff tears) and a control group of volunteers without shoulder conditions. Starting January 2019, 12 patients with a chronic rotator cuff tear were consecutively recruited at the outpatient orthopaedic clinic. Eleven age-matched controls (randomly recruited by posters in the hospital) were included after assuring the absence of shoulder complaints and an intact rotator cuff on ultrasound imaging. The upper limb was examined using the FIT-HaNSA (score: 0 [worst] to 300 seconds [best]), shoulder-specific instruments, health-related quality of life, and EMG recordings of 10 shoulder girdle muscles while performing a tailored FIT-HaNSA.RESULTS: EMG (normalized root mean square amplitudes) revealed hyperactivity of the posterior deltoid and biceps brachii muscles during the upward phase in patients with rotator cuff tears compared with controls (posterior deltoid: 111% ± 6% versus 102% ± 10%, mean difference -9 [95% confidence interval -17 to -1]; p = 0.03; biceps brachii: 118% ± 7% versus 111% ± 6%, mean difference -7 [95% CI -13 to 0]; p = 0.04), and there was decreased activity during the downward phase in patients with rotator cuff tears compared with controls (posterior deltoid: 89% ± 6% versus 98% ± 10%, mean difference 9 [95% CI 1 to 17]; p = 0.03; biceps brachii: 82% ± 7% versus 89% ± 6%, mean difference 7 [95% CI 0 to 14]; p = 0.03). The posterior deltoid functioned less in conjunction with the other deltoid muscles, and lower coactivation was seen in the remaining intact rotator cuff muscles in the rotator cuff tear group than in the control group.CONCLUSION: Patients with a symptomatic rotator cuff tear show compensatory movement patterns based on abnormal activity of the biceps brachii and posterior deltoid muscles when compared with age-matched controls. The posterior deltoid functions less in conjunction with the other deltoid muscles, and lower coactivation was seen in the remaining intact rotator cuff muscles in the rotator cuff tear group than the control group.CLINICAL RELEVANCE: This study supports the potential benefit of addressing the long head biceps tendon in the treatment of patients with a symptomatic rotator cuff tear. Moreover, clinicians might use these findings for conservative treatment; the posterior deltoid can be specifically trained to help compensate for the deficient rotator cuff.

Sprengel deformity is a congenital anomaly arising mainly in the shoulder girdle, associated with elevation of dysplastic scapula. skeletal anomalies, mainly Klippel-Feil syndrome, hemivertebrae, and omovertebral bone may be present along Sprengel anomaly. The omovertebral bone is an abnormal bone that originates from the superomedial edge of the scapula with different insertion points along the posterior cervical spine, seen in about third of the patients with Sprengel anomaly. While cosmetic to functional impairment is a common presentation to the omovertebral bone, cervical myelopathy is a rare presentation. Here, we described our experience, management and follow up of 13-year-old boy presented with cervical myelopathy secondary to the omovertebral bone.

Acute injuries to the shoulder girdle are common and frequently encountered by the practicing radiologist. The type of injury is highly dependent on the age of the patient and mechanism of trauma with injuries occurring at the site of greatest mechanical weakness. In this review, we discuss the main clinical features and key imaging findings for the most common shoulder injuries. For each injury, we also provide a section on the important features that the orthopedic surgeon needs to know in order to guide surgical versus nonsurgical management.

Adhesive Capsulitis (AC) is a common disabling musculoskeletal pain condition of unknown etiology related to the shoulder joint. Literature reported the restricted range of motion (ROM) and pain could be the result of myofascial trigger points (MTrPs) in the muscles of the shoulder girdle. Hence, the objective of this study was to assess the short-term effectiveness of MTrP dry needling (DN) in improving ROM, pain, pressure pain threshold (PPT), and physical disability among patients having AC.In a single group pre-post experimental study design, a total of 70 clinically diagnosed patients (both malefemale, age group between 40 and 65 years) with AC were recruited from three multi-specialty hospitals. The informed consent forms were received from each patient before participating in the study. Each patient received DN for the MTrPs of shoulder girdle muscles for alternative six days. In addition to DN, each patient had received conventional physiotherapy for continuous twelve days which includes electrotherapy modalities and exercises. The pain intensity (visual analog scale), shoulder ROM (Goniometer), disability (shoulder pain and disability index) and PPT (Algometer) were the outcome measures assessed at the baseline and twelfth day of the intervention.There was a statistically significant (p 0.05) improvement in shoulder ROM, pain intensity, shoulder disability, and PPT at the end of the twelve days of intervention as compared to baseline assessment.MTrPs-DN techniques may improve the pain, ROM, disability and PPT along with conventional physiotherapy management among patients with AC.

In baseball pitching, biomechanical parameters have been linked to ball velocity and potential injury risk. However, although the features of a biomechanical model have a significant influence on the kinematics and kinetics of a motion, this influence have not been assessed for pitching. The aim of this study was to evaluate the choice of the trunk and shoulder features, by comparing two models using the same input. The models differed in thoraco-humeral joint definition (moving or fixed with the thorax), joint centre estimation, values of the inertial parameters and computational framework. One professional pitcher participated in the study. We found that the different features of the biomechanical models have a substantial influence on the kinematics and kinetics of the pitchers. With a fixed thoraco-humeral joint the peak average thorax angular velocity was delayed and underestimated by 17% and the shoulder internal rotation velocity was overestimated by 7%. The use of a thoraco-humeral joint fixed to the thorax will lead to an overestimation of the rotational power at the shoulder and will neglect the power produced by the forward and upward translation of the shoulder girdle. These findings have direct implications for the interpretation of shoulder muscle contributions to the pitch.

Objective This investigation measured the reproducibility and discriminant validity of the Posterior Shoulder Endurance Test (PSET) on painful and non-painful populations. Design Reliability and validity study. Setting Laboratory setting. Participants Thirty subjects (male = 11; female = 19). Main outcome measures Time to failure (TTF) was the primary outcome measure to determine reliability of the PSET. Discriminant validity identified with receiver operator characteristic (ROC) curves utilized TTF separately in men and women since they used different loads. Results There were 25/30 subjects (painful = 12; non-painful = 13) tested a second time. ICC, SEM, and MDC90 ranged respectively from 0.77, 13.1 s, 30.6 s in the painful group to 0.85, 7.3 s, 17 s in the non-painful group. The male ROC curve AUC was 0.833 with 47 s resulting in the best combination of sensitivity = 0.833, and specificity = 0.80. The female ROC curve AUC was 0.633 with 46 s resulting in the best combination of sensitivity = 0.600 and specificity = 0.889 at 46 s. Conclusion The PSET is a reliable way to measure shoulder girdle muscular endurance. These data suggest that the PSET discriminates painful and non-painful individuals better in men compared to women.

This study aims to demonstrate the effectiveness of rehabilitation in patients with limb-girdle disease, who were given a home exercise program and called for follow-up in certain periods by observing the functional areas of the shoulder and pelvic groups every six months. Suitable statistical methods were conducted. Descriptive findings and continuous variables regarding the patients were presented. As a result of the analyses, no statistically significant difference was found only in pre-treatment and post-treatment wrist strength and trunk extension variables, but a statistically significant difference was found between the pre-treatment and post-treatment scores of all other types of strength. Significant differences were found between the pre-treatment and post-treatment cervical flexion strength in terms of general weakness and inability to walk, joint limitation and walking status. It is believed that the rehabilitation method to be applied to patients with limb-girdle muscular dystrophy (LGMD) detected in the early period will provide effective results and may form the basis for referring them to physicians and health professionals. It has been concluded that rehabilitation will help them lead a comfortable life.

In the nonoperative treatment of degenerative rotator cuff (RC) tears, exercise therapy is advocated. Exercises focusing on strengthening the anterior deltoid (AD) and the scapular muscles are proposed to compensate for RC dysfunction. However, the amount of electromyographic (EMG) activity in these muscles during these exercises remains unclear. Moreover, it is unknown whether muscle activity levels during these exercises alter with increasing age. Therefore, the purpose of this study was to evaluate EMG activity in the deltoid and scapular muscles during 2 series of commonly used shoulder rehabilitation exercises and assess possible age-related changes in muscle activity.Fifty-five healthy participants (aged 18-60 years) participated in this study. Surface EMG activity was measured in 8 shoulder girdle muscles during a progression of a closed chain elevation program (bench and wall slides) and during a progression of previously published AD exercises. In addition, muscle activity was compared between 3 age categories (18-32 years, 33-46 years, and 47-60 years).The proposed progressions exhibited increasing activity from10% of maximal voluntary isometric contraction to20% of maximal voluntary isometric contraction for the AD for both exercise programs and for the middle deltoid, upper trapezius, and middle trapezius during the closed chain elevation exercises. Activity levels in the other muscles remained20% throughout the progression. Age-related analysis revealed increased activity in the AD, infraspinatus, and middle trapezius and decreased lower trapezius activity during the bench and wall slides. No age-related changes were noted for the AD exercises.These findings may assist the clinician in prescribing appropriate progressive exercise programs for patients with symptomatic RC tears.

Background Facioscapulohumeral muscular dystrophy (FSHD) is a rare condition affecting 1/20,000 persons and the third most common muscular dystrophy condition, with an autosomal dominant pattern of inheritance characterized by progressive muscular weakness primarily involving the face, shoulder girdle, and upper arm. The condition is associated with atrophic musculature of the trunk and core leading to difficulties with gait, posture, and function. FSHD leaves as many as 20% of patients wheelchair-bound and most commonly presents with low back, neck, and shoulder pain. Case Description We present the case of a patient with FSHD who underwent multiple spinal fusion surgeries without relief in her back pain. Imaging studies serve to highlight the extent of paraspinal muscle atrophy and provides the basis for a discussion on the preoperative factors that may predict patients most likely to benefit from surgery. We then provide a brief review of the literature on the role of paraspinal muscle atrophy in back pain. Conclusions This case adds to our understanding of the surgical management of patients with FSHD and patients with atrophic core musculature as a whole.

Until now, classifications of coracoid fractures have been based on plain radiographs, without use of 3D CT reconstructions. Therefore, the aim of the present study has been to describe the pathoanatomy of these fractures and their associated injuries to the shoulder girdle, on the basis of 3D CT reconstructions. The cohort comprised 39 patients, who each sustained a coracoid fracture investigated with 3D CT reconstructions. The patients were assessed in terms of age, gender, pathoanatomy of the coracoid fracture, fractures of other parts of the scapula, and associated injuries to the shoulder girdle. We identified 24 fractures of the base, one fracture of the beak body, eight fractures of the apex, and six comminuted fractures of the coracoid process. A total of 22 associated injuries were found (7 fractures of the acromion, 5 fractures of the anterior glenoid rim, 3 fractures of the superior glenoid, 1 fracture of the inferior glenoid, 4 fractures of the surgical neck, 2 fractures of the scapular body) and 18 other associated injuries to the shoulder girdle (8 AC dislocations, 5 proximal humeral fractures, and 5 clavicular fractures). On the basis of 3D CT reconstructions, four basic coracoid fracture patterns were identified. The authors´ findings and literature review have shown that a considerable number of coracoid fractures are combined with injuries to other parts of scapula and shoulder girdle. These associated injuries must be taken into account and targeted when taking the patient’s history, and during clinical and primarily radiological examinations.

Context The shoulder joint and girdle are highly loaded during field hockey play. To optimize performance and to better substantiate preventive programs, it is important to gain insight into shoulder-girdle muscle function and balance in this athlete population. Objective To evaluate relative scapular muscle-activity ratios through surface electromyography during maximal isokinetic strength testing in elite male field hockey players compared with nonathletes. Design Cross-sectional study. Setting Institutional laboratory. Patients or Other Participants Twenty-five elite field hockey players from the Belgian National Team and 25 age- and sex-matched nonathletes. Intervention(s) We measured bilateral activity in 4 scapular muscles (upper trapezius [UT], middle trapezius [MT], lower trapezius [LT], and serratus anterior [SA]) during an external-internal rotation and protraction-retraction isokinetic shoulder protocol. Main Outcome Measure(s) Relative scapular muscle-activity ratios, or balance ratios, of the UT : MT, UT : LT, UT : SA, SA : MT, and SA : LT. Results We noted lower ratios bilaterally in the athlete group compared with the control group for the UT : MT, UT : LT, and SA : MT ratios during protraction, retraction, and external rotation, respectively, and unilaterally (dominant side only) for the UT : LT ratio during protraction. No consistent trend was present for established side differences in the studied balance ratios. Conclusions Compared with nonathletes, elite field hockey players had altered intramuscular (within the trapezius) and intermuscular (between the trapezius and SA) balance ratios during maximal shoulder-girdle contractions, with relatively more MT and LT activity. This may reflect a sport-specific adaptation to optimize coordinated activity of the scapulothoracic muscles, meeting the specific demands of field hockey movements and simultaneously better protecting the shoulder against injury. Our results can assist in optimizing high-performance training and in supporting injury-prevention programs, which are key to both successful and long-lasting athletic careers.

Background Osseous tumors of the shoulder girdle occur most frequently in the proximal humerus, scapula and clavicle. Prior studies have determined that tumors occurring in the scapula have a higher risk of malignancy, but few have looked exclusively at tumors of this site to describe incidence, clinical features and potential predictors of malignancy. As imaging technologies for diagnosis have improved, it is important to re-evaluate if patterns of incidence have changed and if new imaging findings could potentially be predictors of malignancy. Methods This retrospective analysis identified 173 patients from a pediatric and an adult hospital between 1990 and 2015. All patients with tumors of the scapula either of bony origin or with bony invasion were included. Diagnosis, tumor location, and patient demographics were collected. Bivariate and logistic regression analyses were performed to identify potential predictors of malignancy. Results Chondrosarcoma and osteochondroma were the most common malignant and benign tumors, respectively. Benign tumors were more prevalent in the pediatric population. Tumors occurred most frequently in the body of the scapula. Risk for malignancy increased with age (OR 1.09, 95% CI 1.05–1.12), tumors invading multiple sites (OR 10.85, 95% CI 2.37–49.72) and tumors that were lucent (OR 7.02, 95% CI 1.14–43.21) or had a mixed radiographic appearance (OR 11.47, 95% CI 1.36–99.65). Conclusions Including neoplasia in the differential diagnosis for shoulder complaints is important because the scapula is a site of increased risk of malignancy. Patterns of incidence and prevalence have not changed in the last years with the use of more advance techniques of imaging studies. Older age, lucent or mixed imaging, and tumors that span multiple sites of the scapula were found to be predictors of malignancy. Additional cross-sectional anatomy studies may be warranted for further evaluation in patients presenting with these characteristics given the higher concern for malignant disease. Level of evidence Level IV, Prognostic Study.

In male handball, limited knowledge exists about the body posture and postural control in correlation to their injury occurrence and their impact on physical constitution. 91 male handball players participated and were asked about playing position and years, NSAIDs intake, sustained injuries and therapy duration. A three-dimensional back scanner and a pressure measuring plate were used. Shoulder injuries cause a differing scapular height and increase the vertebrae rotation in correlation to playing years. Lower limb injuries lead to a decrease on the Centre of Pressure (CoP) with growing game experience. Wing players show the lowest injury risk. Lower limb and shoulder girdle are mostly affected regarding the incidence of injuries. Pivot players suffer most injuries in the lower limb area (59%), whereas wing players mostly have shoulder injuries (19%). Being injured, 21% of the players continue playing, 79% pause for a minimum of six months (25%). No correlation can be determined between level of profession, use of NSAIDs and body posture or postural control. Playing position, employment situation or NSAIDs have no influence on type of injury, body posture or postural control. While shoulder injuries can be recognized in the vertebrae area, lower limb injuries can affect the CoP.

The upper extremity posture is characteristic of each Carnegie stage (CS), particularly between CS18 and CS23. Morphogenesis of the shoulder joint complex largely contributes to posture, although the exact position of the shoulder joints has not been described. In the present study, the position of the upper arm was first quantitatively measured, and the contribution of the position of the shoulder girdle, including the scapula and glenohumeral (GH) joint, was then evaluated. Twenty-nine human fetal specimens from the Kyoto Collection were used in this study. The morphogenesis and three-dimensional position of the shoulder girdle and humerus were analyzed using phase-contrast X-ray computed tomography and magnetic resonance imaging. Both abduction and flexion of the upper arm displayed a local maximum at CS20. Abduction gradually decreased until the middle fetal period, which was a prominent feature. Flexion was less than 90° at the local maximum, which was discrepant between appearance and measurement value in our study. The scapular body exhibited a unique position, being oriented internally and in the upward direction, with the glenoid cavity oriented cranially and ventrally. However, this unique scapular position had little effect on the upper arm posture because the angle of the scapula on the thorax was canceled as the angle of the GH joint had changed to a mirror image of that angle. Our present study suggested that measuring the angle of the scapula on the thorax and that of the GH joint using sonography leads to improved staging of the human embryo.

Case A 21-year-old woman with a history of multiple failed surgical and conservative management for recurrent involuntary shoulder instability presented with 1-year history of shoulder pain. Physical examination demonstrated intractable static anterior glenohumeral instability, deficient capsular tissue, with reducible scapular winging secondary to long thoracic nerve palsy. Allograft capsular reconstruction and open split pectoralis major tendon transfer were performed to salvage shoulder motion and stabilize her shoulder girdle. Conclusion This report presents a novel repair option for intractable shoulder instability and scapular winging. Surgeons should recognize potential causes of shoulder instability and familiarize themselves with multiple stabilization techniques as potential salvage options before glenohumeral fusion.

Septic arthritis of the smaller acromioclavicular joint is uncommon, with only a few reports and case series available in the literature. The aim of this outcomes analysis was to determine the prevalence of shoulder girdle septic arthritis within the authors' institution, with a particular focus on describing the authors' experience with acromioclavicular joint septic arthritis. A retrospective outcomes analysis was conducted of patients admitted to a single tertiary referral center from 2008 to 2018 with acromioclavicular joint septic arthritis. Demographic and clinical data were recorded for each patient; the modified Frailty Index score was calculated for each patient. Nine patients were identified as having acromioclavicular joint septic arthritis, making up 12% of shoulder girdle septic arthritis. Diabetes mellitus was the most prevalent comorbidity, present in 4 (44.4%) patients. Staphylococcus aureus was responsible in 55.6% and Streptococcus species in 44.4%. Seven patients were treated surgically. Mean (SD) length of antibiotic therapy was 6.2 (2.7) weeks. Mean (SD) length of stay was 6 (2.83) days (range, 4–8 days) for patients who received antibiotic therapy only and 12.7 (7.52) days for those who proceeded for operative management. Mean modified Frailty Index score was 1.1. Septic arthritis of the acromioclavicular joint is an uncommon infection that occurs both in patients with impaired immunity and in those with intact immune systems. Tailored antimicrobial therapy in conjunction with surgical intervention, when indicated, appears to result in successful suppression or eradication of infection in the majority of cases. [ Orthopedics . 2021;44(4):e493–e497.]

We found four patients with some characteristic phenotype in our ICU, characterized by focal hypotrophies of the shoulder girdle and the bilateral peroneal district and underlying critical illness neuro-myopathy. In our opinion, these hypotrophies are secondary to the prone position. Is our intention to start early treatment protocol with electrostimulation to evaluate the effectiveness in the prevention of critical illness and focal hypotrophies in ICU SARS-CoV-2 patients, to increase chances of returning to a preinfection functional status.

Posterior glenohumeral instability can manifest as posterior shoulder pain and dysfunction, particularly among athletes. Repetitive, posteriorly-directed axial loads, as commonly encountered by contact athletes (American football linemen, rugby players), result in microtrauma that can induce posteroinferior labral tears. Alternatively, SLAP tears commonly seen in throwing athletes may propagate in a posteroinferior direction (i.e., a type VIII SLAP tear), owing to a complex pathologic cascade involving glenohumeral capsular contracture and imbalances among the dynamic stabilizing muscles of both the glenohumeral joint and shoulder girdle. The diagnosis of posterior glenohumeral instability is elucidated by a thorough history and physical examination. Posterior shoulder pain is oftentimes insidious in onset. The throwing athlete with posterior glenohumeral instability may complain of diminished control, accuracy, and generalized shoulder discomfort. A number of provocative physical examination maneuvers have been described (Kim test, Jerk test), which load the humeral head against the labral lesion and recreate patients' symptoms. Magnetic resonance imaging and magnetic resonance arthrography can be of value in demonstrating avulsions of the labrum from the posteroinferior glenoid, and computed tomography is useful for quantifying the location and amount of attritional glenoid bone loss, although in contradistinction to anterior glenohumeral instability, clearly defined thresholds that would otherwise guide treatment have not been established. In the absence of substantial bone loss, arthroscopic posterior capsulolabral repair remains the gold standard for the surgical management of symptoms refractory to nonoperative treatment, and excellent clinical outcomes have generally been reported. However, high rates of return to play at the previous level of participation, particularly among throwing athletes, have been less consistently observed. Risk factors for the need for revision stabilization include surgery on the dominant extremity, female sex, and capsulolabral repairs involving either anchorless techniques or the use of less than 4 anchors.

A 74-year-old woman presented with a 6-month history of malaise, generalized fatigue, significant unintentional weight loss, and night sweats, as well as pain, weakness, and stiffness in the shoulder girdle most severe in the morning. She reported no headache, visual disturbances, or jaw

Background Improved knowledge of normal shoulder girdle proprioception should benefit the treatment and rehabilitation of shoulder disorders. Whereas many of the available methods for assessing joint position sense (JPS) are costly and complex, Balke et al. have described a simple test. The primary objective of this study was to use this test to identify factors that influence shoulder-girdle JPS evaluation in healthy individuals. The secondary objective was to determine reference values based on the values obtained and on the factors associated with their variability. Hypothesis Age and dominant limb influence the results of shoulder girdle JPS evaluation, creating a need for reference values that take these factors in account. Patients and methods A single-centre prospective study of healthy volunteers was performed between September 2012 and January 2013. In each volunteer, shoulder repositioning accuracy was assessed bilaterally as described by Balke et al. A line was drawn on the floor parallel to and 1 metre away from a wall. A target on the wall showed marks corresponding to three angles of arm elevation: 55°, 90°, and 125°. The volunteer was asked to raise the arm to the three positions, in abduction and in flexion, while memorising the joint positions, then to replicate the same positions with the eyes closed. The absolute differences between the replicated positions and the reference positions, designated angle deviations, were measured in degrees. Age, sex, and dominant upper limb were recorded. Results The 88 shoulders of 44 healthy volunteers were studied. No significant difference was found between males and females (p > 0.05). The only significant difference between sides was better replication by the dominant arm of flexion at 55° (p = 0.03). By univariate analysis, age was the only factor significantly associated with repositioning errors (p = 0.003); neither dominant limb nor sex were significant (p = 0.29 and p = 0.59, respectively). In flexion, the angle deviation increased significantly with movement amplitude. The measurements were used to create a chart of expected angle deviations in healthy individuals according to age and to plane and amplitude of movement. Discussion The test described by Balke et al. is simple and feasible in everyday practice. Age, dominance, and plane of movement should be considered when evaluating abnormal shoulders. Further studies in larger numbers of individuals are needed to better define normal angle deviations related to these factors. Level of evidence IV.

Background Shoulder impingement syndrome is considered to be associated with an altered muscular activity, which is related to strategy changes in the movement plan. The present study aimed to investigate the differences in timing and intensity of activity of shoulder girdle muscles while performing a forehand topspin loop between elite table tennis players with and without shoulder impingement syndrome. The timing and activity amplitude of these shoulder girdle muscles have not been evaluated in other studies in table tennis elite athletes. Methods Activation timing and activity levels of the upper trapezius, lower trapezius, and serratus anterior, anterior deltoid, supraspinatus, and biceps brachii muscles were measured in 30 table tennis players (Premier League tournament level or higher) with shoulder impingement syndrome and compared with 30 same-level healthy players while performing the forehand topspin loop. Results The results indicated that the activity levels of the serratus anterior (P = .007) and supraspinatus (P = .001) muscles significantly decreased; however, the activity level of the upper trapezius significantly increased in the impingement compared with the healthy group (P = .009). The serratus anterior (P = .001) was activated significantly later, but the upper trapezius (P = .004) was activated significantly earlier in the impingement group. Conclusion Results of the present study support the theory that the activation and sequence of recruiting of the shoulder muscles are altered in people with impingement symptoms, suggesting that impingement syndrome may be associated with disturbed timing and activity level of shoulder girdle muscles.

Introduction Limb-girdle muscular dystrophy (LGMD) consists of over 30 genetic conditions with varying clinical phenotypes primarily affecting pelvic girdle, shoulder girdle, and other proximal limb muscles. Studies focusing on the physical, mental, and social effects of this disease from the patient's perspective are limited. Methods Adults with LGMD were interviewed and asked to identify issues that have the greatest impact on their quality of life. Each interview was recorded, transcribed, coded, and analyzed. Results Participants provided 1385 direct quotes. One hundred sixty-five potential symptoms of importance were identified and grouped into 15 larger themes. The most frequently reported themes included limitations with mobility, difficulty performing activities, social role limitations, and emotional distress. Discussion There are multiple symptoms that alter the lives of adults with LGMD. These affect their physical, emotional, and social health, and may be amenable to medical intervention.

Shoulder girdle trauma is one of the most common injuries encountered in emergency centers. These injuries can be easily overlooked due to the complex osteology of the shoulder. Although radiographs are usually sufficient for assessing traumatic shoulder injuries, cross-sectional imaging is sometimes indicated to assess portions of the shoulder not well visualized by radiographs. In this article, the authors review the spectrum of shoulder girdle injuries: sternoclavicular dislocations, clavicle fractures, acromioclavicular separations, shoulder dislocations, scapula fractures, and scapulothoracic dissociation. They also discuss the presentation, imaging evaluation, and classification of these injuries with emphasis on pitfalls in imaging diagnosis and indications for computed tomography/magnetic resonance.

Objective Different classification systems for surgical tumor resections in the proximal humerus and scapula have been described, but none are specific or have been recently revised. The purpose of this article is to report modified surgical techniques and a new classification system for resections in the humerus and scapula. Methods Thirty-two patients with shoulder girdle bone tumors were operated upon. Two separate new classifications were assigned to resections in the humerus (types I–IV) and scapula (types I–III). An annotation is added to signify deltoid preservation (A) or sacrifice (B). Modified surgical techniques were devised. Results For extra-articular resections of the proximal humerus, we show that sacrificing the acromion and coracoid process is not required. Preservation of these structures can improve cosmetic shoulder outcome. For tumors with no large medial component, we show that there is no need to detach the muscle attachment from the coracoid process allowing earlier elbow extension postoperatively. After a mean follow-up period of 46 months, only two patients developed local recurrence. Postoperative infection was seen in two and stem loosening in one patient. The average MSTS functional score for all patients was 83%. Conclusion Our modified surgical techniques saved structures which were unnecessarily resected with no advantage in surgical series. We reserved the integrity of more muscular tissues and attachments leading to less restriction during the rehabilitation process. This new classification system is realistic, easy to implement, and applicable to all patients.

In every country in the world, there are a number of amputees who have been exposed to some accidents that led to the loss of their upper limbs. The aim of this study is to suggest a system for real-time classification of five classes of shoulder girdle motions for high-level upper limb amputees using a pattern recognition system. In the suggested system, the wavelet transform was utilized for feature extraction, and the extreme learning machine was used as a classifier. The system was tested on four intact-limbed subjects and one amputee, with eight channels involving five electromyography channels and three-axis accelerometer sensor. The study shows that the suggested pattern recognition system has the ability to classify the shoulder girdle motions for high-level upper limb motions with 88.4% average classification accuracy for four intact-limbed subjects and 92.8% classification accuracy for one amputee by combining electromyography and accelerometer channels. The outcomes of this study may suggest that the proposed pattern recognition system can help to provide control signals to drive a prosthetic arm for high-level upper limb amputees.

The purpose of study was to determine and compare electromyographic activity of selected shoulder girdle muscles in elite swimmers with and without shoulder pain. Twelve professional swimmers with shoulder pain (mean age: 18.55±3.16 years, body mass: 74.33±2.91 kg, and height: 179.00±5.29cm) and twelve swimmers without pain (mean age: 18.11±1.61 years, body weight: 73.33±6.06 kg, height: 178.33±5.07cm) were recruited. Surface electromyography signals were collected from seven upper limb muscles during a task: participants were instructed to mark points with a pen within each of the 3 circles counterclockwise. The normalised root-mean-square value was used to determine the muscular activation. Swimmers with shoulder pain demonstrated greater activation of the upper trapezius (pain group mean: 28.04±10.37, control group mean: 13.40±06.04; p=0.002, partial eta square: 0.455), serratus anterior (pain group mean: 30.78±20.09, control group mean: 13.30±5.52; p=0.023, partial eta square: 0.283) and latissimus dorsi (pain group mean: 27.05±17.87, control group mean: 4.99±3.90; p=0.002, partial eta square: 0.450) muscles. There was no difference (p>0.05) in the activation of the middle and lower trapezius, middle deltoid and sternocleidomastoid. The altered muscle activation patterns may contribute to the painful shoulder in elite swimmers and need to be considered within the rehabilitation interventions.

Introduction Here we report a case study of an experienced amateur female racing driver (age = 59) with self-reported fatigue of the muscles of the shoulder girdle post bilateral mastectomy and breast reconstruction. This case study describes how adjustment of her driving posture affected measures of muscle fatigue (sEMG) and driving performance (lap-time). Methods Bilateral surface electromyographic activity of sternocleidomastoid, cervical erector spinae, anterior deltoid and pectoralis major, angles of inclination of the cervical and lumbar spine in the sagittal plane and lap-times were measured at: 1) baseline, 2) after an initial adjustment of driving posture, and 3) after a readjustment of driving posture. Mean lap-times improved from 136.81 s (SD = 2.12) at baseline to 134.63 s (SD = 1.8) after readjustment. Results Both sternocleidomastoid and left cervical erector spinae fatigued more slowly after readjustment but right cervical erector spinae fatigued more quickly. There was no change in the rates of fatigue of either pectoralis major or anterior deltoid. Conclusion The improvement in her performance was associated with a change in the posture and movement pattern of her head rather than her shoulder girdle. It is likely that this improved her ability to visually perceive and steer the racing line.

Clinical introductionA healthy 8-year-old boy presented to the ED with acute left shoulder pain. He had been playing football and his left arm was pulled by an opposition team member. He fell to the ground and landed on his left shoulder causing pain. On examination after analgesia, active and passive movement of the shoulder joint was possible in all directions but range of motion was limited by pain. There was no visible swelling or bruising throughout the shoulder girdle. A radiograph of the shoulder was obtained (figure 1).Figure 1Plain radiograph of the left shoulder.QuestionWhat radiographic finding is seen for this patient?Glenohumeral lipohaemarthrosis.Acromioclavicular joint disruption.Intra-articular gas.Intra-articular loose body.

This case describes a 16-year-old boy who suffered a severe traumatic brain injury. The patient gradually recovered but developed debilitating spasticity mainly in left triceps muscle, abnormal positioning of shoulder girdle complex, and shoulder pain. Phenol (6%) was injected to axillary and radial nerves under the guidance of electrical stimulation and ultrasound imaging at 10 weeks after the initial injury. After injection, triceps spasticity and shoulder pain were immediately reduced, and abnormal positions of shoulder girdle complex and elbow joint gradually returned to functional limits over 2 weeks. This case suggests that phenol neurolysis for spasticity management in early recovery could yield functional recovery.Level of Evidence: V.

Patient: Female, 27-year-old Final Diagnosis: Giant cell tumor of bone Symptoms: No symptom Medication:— Clinical Procedure: — Specialty: Oncology Objective: Rare disease Background: Giant cell tumor of bone (GCTB) is a locally aggressive, intermediate tumor that rarely metastasizes. GCTB typically affects the ends of long bones and rarely involves the ribs. Curettage is typically the treatment of choice for GCTB in long bones. However, the optimal treatment of GCTB in ribs remains unclear. We report the case of a patient with asymptomatic GCTB of the first rib that was successfully treated with combined preoperative denosumab therapy and surgery via a transmanubrial approach without resection of the clavicle. Case Report: A healthy 27-year-old woman presented with a bone tumor involving the left first rib that was incidentally discovered on routine chest X-ray. Histological examination of core-needle biopsy specimens of the lesion led to a pathological diagnosis of GCTB. After preoperative denosumab treatment for 6 months, en bloc resection via a transmanubrial approach was performed. There were no serious postoperative complications. The patient remained free of symptoms and had no recurrence 4.5 years after surgery. Conclusions: Compared with other ribs, masses located in the first rib can be challenging to treat surgically because of the clavicle and neighboring neurovascular structures. This report is the first to describe GCTB located on the anterior aspect of the first rib that was successfully treated with combined preoperative denosumab therapy and surgery via a transmanubrial approach, with no recurrence or functional impairment of the shoulder girdle.

The biomechanical complexity of the human shoulder, while critical for functionality, poses a challenge for objective assessment during sensorimotor rehabilitation. With built-in sensing capabilities, robotic exoskeletons have the potential to serve as tools for both intervention and assessment. The bilateral upper-extremity Harmony exoskeleton is capable of full shoulder articulation, forearm flexion-extension, and wrist pronation-supination motions. The goal of this paper is to characterize Harmony’s anatomical joint angle tracking accuracy towards its use as an assessment tool. We evaluated the agreement between anatomical joint angles estimated from the robot’s sensor data and optical motion capture markers attached to the human user. In 9 healthy participants we examined 6 upper-extremity joint angles, including shoulder girdle angles, across 4 different motions, varying active/passive motion of the user and physical constraint of the trunk. We observed mostly good to excellent levels of agreement between measurement systems with $\textit {CMC}_{\textit {ip}} \,\, {>} \,\, {0.65}$ for shoulder and distal joints, magnitudes of average discrepancies varying from 0.43° to 16.03° and width of LoAs ranging between 9.44° and 41.91°. Slopes were between 1.03 and 1.43 with r > 0.9 for shoulder and distal joints. Regression analysis suggested that discrepancies observed between measured robot and human motions were primarily due to relative motion associated with soft tissue deformation. The results suggest that the Harmony exoskeleton is capable of providing accurate measurements of arm and shoulder joint kinematics. These findings may lead to robot-assisted assessment and intervention of one of the most complex joint structures in the human body.

Introduction Tumors of the scapula are rare representing only 1.6%-2.8% of all skeletal tumor localizations. Wide resection of these tumors is often necessary, and their anatomic location is the most decisive factor for the extent of the resection. Because of the importance of the shoulder girdle for all daily activities, such resections can have major functional consequences. However, only few reports with small numbers of cases are found in the literature. Patients and methods We retrospectively evaluated 31 consecutive patients with scapular tumors treated surgically for aggressive benign or malignant tumors of the scapula. Patients who had received curettage only were excluded. Four of these 31 patients were lost to follow-up. In 7 of the remaining 27 patients, a total scapulectomy had to be performed, whereas all others received a partial resection. In 1 case, a partial resection and replantation after irradiation was performed. Musculoskeletal Tumor Society Scoring System (MSTS) and Toronto Extremity Salvage Score (TESS) scores were evaluated postoperatively at the time of their follow-up. Results In 16 men and 11 women, the median age was 46.2 years and the tumor entities were heterogeneous. The median follow-up time was 71 months. Three patients died during follow-up due to their tumor and 1 due to cardiac disease. We found significantly better functional results in the group with incomplete scapula resections as opposed to the scapulectomy group. We did not see a significant functional difference between the patients with benign and those with malignant lesions. Both the MSTS score with median 83.3% (range between 23% and 100%) and the TESS score with 81.6% (ranging from 20.4% to 100%) were at a satisfactory level. The preservation of the supraspinatus muscle was shown to be advantageous for better shoulder function, and younger patients also tended to have better postoperative results. Conclusion The resection of scapular tumors may lead to a significant functional disability of the shoulder girdle and the affected arm in many cases. However, this is represented neither in the MSTS or TESS score nor in the overall acceptance of the patients. Only 1 patient, an artisan, had to change his job. In total, the clinical results are quite good in short- and long-term follow-up. The score results were comparable to other studies.

The goal of our study was to examine the muscle activity of the shoulder girdle after isokinetic fatigue, which may simulate muscle activities commonly occurring during specific sport-related activities in recreational overhead asymptomatic athletes. We hypothesized that exercise-induced fatigue, reported after isokinetic protocols, may cause a decrease in the median frequency (MF) of the upper trapezius (UT), infraspinatus (IS), and deltoid muscles. Twenty-four male overhead volleyball (n = 8), handball (n = 8), and tennis (n = 8) athletes participated in this study. All subjects were without shoulder injury history. The surface electromyography (SEMG) was collected on the right (dominant) side of the shoulder girdle muscles in the following order: UT, IS and anterior (DA), and posterior deltoideus (DP). The fatigue protocol consisted of three sets of 32 maximum isokinetic concentric contractions while performing shoulder internal and external rotation at an isokinetic speed of 120 o/s. The resultant difference in median frequency (ΔMF) values consistently dropped after the fatiguing tasks across all recorded muscles, in terms of the initial MF (MFINI = 65.1 ± 1.1 Hz) and final MF (MFFIN = 57.9 ± 0.9 Hz), and the main effect of time was significant (F(1,22) = 43.15, p &lt, 0.001). MF values decreased mostly for IS (ΔMFIS = −9.9 ± 1.6 Hz) and DP (ΔMFPD = −9.5 ± 1.9 Hz) muscles, while DA and UT showed smaller changes (ΔMFDA = −6.9 ± 1.5 Hz) and (ΔMFUT = −3.2 ± 1.3 Hz). The results of our study show a meaningful contribution in determining increased fatigue of the shoulder girdle muscles during repeated isokinetic internal-external rotation protocols. We have also demonstrated a significant decrease in MF in all examined muscles, especially IS and DA.

Anatomical reconstruction of the coracoclavicular ligaments involves drilling the base of the coracoid or looping a graft around it, placing the axillary nerve at risk for injury. Rockwood type V acromioclavicular (AC) separation injuries involve disruption of the AC joint capsule and coracoclavicular ligaments, resulting in inferomedial displacement of the scapulohumeral complex and alteration of the normal anatomical relations of the shoulder girdle structures. This study evaluated the effect of Rockwood type V AC separation on the anatomical relation of the axillary nerve to the coracoid base. Ten shoulders of 6 adult human cadavers were dissected to determine the dimensions of the coracoid. A digital caliper was used to measure the coracoclavicular distance and the minimal distance between the coracoid base and the axillary nerve. A Rockwood type V AC separation was created by transecting the AC joint capsule and coracoclavicular ligaments, and applying 15 kg of longitudinal tension to the upper extremity. Changes in the distance between the coracoid base and the axillary nerve were measured. Mean width, length, and thickness of the coracoid was 15.05±0.93 mm, 23.1±1.75 mm, and 11.88±1.33 mm, respectively. Mean distance between the coracoid base and the axillary nerve was 26.0±3.9 mm. After simulated Rockwood type V AC separation, mean distance was 22.0±3.4 mm; this difference was statistically significant ( P =.0263; 95% CI, 2.0–5.9 mm). The axillary nerve is closer to the coracoid base during simulated Rockwood type V AC separation than previously reported in the orthopedic literature. Anatomical reconstruction of the coracoclavicular ligaments for Rockwood type V AC separation presents a higher risk for axillary nerve iatrogenic injury than previously reported. [ Orthopedics . 2021;44(1):e68–e72.]

CASE We report a rare variant of sternoclavicular joint (SCJ) dislocation, namely locked anterior-inferior dislocation, with unique clinical, radiographic, and intraoperative findings. In this variant, the medial clavicle was displaced anteriorly and inferiorly and locked in the manubrial-intercostal space, with corresponding mechanical dysfunction of the ipsilateral shoulder girdle joints. Symptoms unique to this variant included painful neck spasms and limited glenohumeral elevation. Nonsurgical treatment was not successful, and open reduction and ligament reconstruction resulted in correction of the fixed deformity with resolution of the clinical symptoms. CONCLUSION Locked anterior-inferior SCJ dislocation is indicated for early open reduction and ligament reconstruction.

Background: Chronic joint injury of the elbow joint is common in patients with hemophilia. Myofascial release is used for the management of pain and functionality in patients with chronic restrictions. Objective: To evaluate the effectiveness of myofascial release in patients with hemophilic elbow arthropathy. Methods: Sixty-nine patients with hemophilia took part in this randomized controlled trial. They were recruited from 10 hemophilia patient Associations. They were randomly allocated to experimental (n = 35) or control group (n = 34). The intervention consisted of three 50-min sessions of fascial therapy over a 3-week period. The intervention included 11 bilaterally administered maneuvers in both upper limbs (from shoulder girdle to forearm). The study variables were frequency of elbow bleeding (self-report), joint status (Hemophilia Joint Health Score), and joint pain (visual analog scale) at baseline, after the intervention, and at the 3-month follow-up. Results: There were significant changes (P < .001) in the repeated measures factor in the frequency of hemarthrosis (F = 20.64), joint status (F = 31.45), and perceived joint pain (F = 30.08). We found group interaction with the (P < .001) in the frequency of hemarthrosis (F = 21.57), joint status (F = 99.98), and perceived joint pain (F = 44.26). There were changes (P < .01) in the pairwise comparison analysis between the pretreatment assessment and the posttreatment and follow-up assessments. Conclusions: Myofascial release decreases frequency of elbow bleedings, and improved joint status and perception of elbow pain in patients with hemophilic elbow arthropathy. Myofascial release may be recommended to improve joint status and joint pain in patients with hemophilic elbow arthropathy. Sin financiación 1.889 JCR (2020) Q3, 99/167 Medicine, General & Internal 0.590 SJR (2020) Q2, 1149/2448 Medicine (miscellaneous) No data IDR 2020 UEM

The acromioclavicular joint represents the link between the clavicle and the scapula, which is responsible for the synchronized dynamic of the shoulder girdle. Chronic acromioclavicular joint instability involves changes in the orientation of the scapula, which provokes cinematic alterations that might result in chronic pain. Several surgical strategies for the management of patients with chronic and symptomatic acromioclavicular joint instability have been described. The range of possibilities includes anatomical and non-anatomical techniques, open and arthroscopy-assisted procedures, and biological and synthetic grafts. Surgical management of chronic acromioclavicular joint instability should involve the reconstruction of the torn ligaments because it is accepted that from three weeks after the injury, these structures may lack healing potential. Here, we provide a review of the literature regarding the management of chronic acromioclavicular joint instability. Level of evidence Expert opinion, Level V.

CASE A 20-year-old woman presented with recurrent bilateral shoulder instability concurrent with severe, treatment-refractory epilepsy. Imaging revealed glenoid bone loss of 25% to 28% and large Hill-Sachs defects bilaterally. Bone graft augmentation of the glenoid and infill of the Hill-Sachs defects was performed bilaterally. Perioperative neuromuscular paralysis of shoulder girdle muscles with botulinum toxin was performed to facilitate recovery. Both shoulders at 2.5 and 4 years, respectively, demonstrate excellent stability and radiographic union despite continued seizure activity. CONCLUSION Perioperative neuromuscular paralysis with botulinum toxin may provide early graft protection after the surgical treatment of glenohumeral instability because of seizures.

SUMMARY Posterior sternoclavicular joint (SCJ) dislocations are rare shoulder girdle injuries. Despite the paucity of cases, posterior SCJ dislocations pose an important threat to patient safety because of the proximity of the medial clavicle to the mediastinum, resulting in possible compression and/or injury to these structures. Current guidelines recommend attempting closed reduction in the acute setting followed by open reduction if closed reduction is unsuccessful. This video highlights a case of posterior SCJ dislocation in a pediatric patient who presented with dyspnea after a football injury.

Objectives: Forward head posture (FHP) is one of the most common musculoskeletal disorders that appears to affect the shoulder joint through the shared muscles between the head and neck area and the shoulder girdle. The present study compared the acromiohumeral distance between individuals with normal head and neck alignment and those with moderate and severe FHP in active and passive arm elevation. Methods: Based on the craniovertebral angle, 60 volunteers were selected and equally distributed among three groups, including group one with normal head and neck alignment, group two with moderate FHP and group three with severe FHP. The space between the humeral head and the acromion was measured in 10°, 45° and 60° of active and passive arm elevation as the acromiohumeral distance. Results: The acromiohumeral distance was only different between the three groups at 45° arm elevation angle, and this difference was significant between groups one and three. In active and passive arm elevation, increased arm elevation angle reduced the subacromial space significantly. Also, in each arm elevation angle, the subacromial space differed significantly between the active and passive arm elevations. Conclusions: The acromiohumeral distance was significantly lower in the severe FHP group than the group with normal head and neck alignment in the 45° active arm elevation angle, which could be due to the changed tension in tissues between active and passive arm elevation and also the maximum muscle activity in the 45° active arm elevation angle.