Can we accelerate rehabilitation following reverse shoulder arthroplasty? A systematic review

Background

There is no consensus concerning the rehabilitation protocol following reverse shoulder arthroplasty. Several patients are expecting to be able to use their arms for sports or recreation shortly after their operation.

Methods

This review was designed as an intervention systematic review with narrative analysis. Authors searched English literature in PubMed and Embase databases from 1/1/1989 until July 2022. Controlled studies comparing rehabilitation protocols for patients undergoing reverse shoulder arthroplasty were included. Data quality was examined with the Cochrane risk of a bias assessment tool for randomized trials, the Methodological Index for Non-Randomized studies (MINORS) tool, as well as the Grading of Recommendations Assessment Development and Evaluation (GRADE) approach.

Results

Three studies were finally analyzed. At 3 months post-op, forward flexion was found to be significantly higher in the early rehabilitation group (140.5, 95% confidence intervals (CIs): 135.10-145.89; the delayed rehabilitation group mean was 131.24, 95% CI: 125.73-136.74; p = 0.019). Twelve months post-op, no significant difference in any clinical or patient-reported outcome was shown. More complications were reported in the 6 weeks-delayed rehabilitation group.

Discussion

Newer regimes permit immediate shoulder mobilization but may not be applied to every patient. The lack of strong evidence warrants the need for future controlled studies; subsequently, postoperative rehabilitation should be individualized.

Patient Preferences and Their Effects on Rehabilitation Outcomes: A Secondary Analysis of a Randomized Controlled Trial

OBJECTIVE: To assess the effect of aligning patients' preferences with specific rehabilitation delivery modes on rehabilitation outcomes. DESIGN: A secondary analysis of a randomized controlled trial (RCT). METHODS: The study cohort comprised 208 patients referred for physiotherapy rehabilitation after non-surgical or surgical interventions for rotator cuff injury, shoulder impingement, or acromioclavicular osteoarthritis. Participants were randomly assigned to one of three rehabilitation modalities: 1) group-based exercise, 2) individual exercise, or 3) home exercise. In this study, participants were categorized into two groups: "matched preference" (MP) and "unmatched preference" (UP). The primary outcome measure was change in function, measured with the shortened Disabilities of the Arm, Shoulder and Hand (QuickDASH). Secondary outcome measures were change in pain, assessed using the Numeric Rating Scale (NRS), mental well-being measured with the World Health Organization Well-Being Index (WHO-5), health-related quality of life assessed using the EuroQol-5Domain questionnaire (EQ-5D), fear avoidance assessed using the Örebro Musculoskeletal Pain Questionnaire (ÖMPQ), and overall treatment satisfaction. Outcomes were assessed at 3 and 6 months. RESULTS: The primary outcome measure, QuickDASH, showed no significant differences between groups at either 3 months (-3.0 [-8.2 to 2.3]) or 6 months (0.5 [-5.7 to 6.7]). Additionally, no significant differences were observed in the secondary outcome measures. CONCLUSION: Matching patients' preferences for specific rehabilitation delivery modes did not seem to effect rehabilitation outcomes.

Experiences of physiotherapists considering virtual reality for shoulder rehabilitation: A focus group study

Introduction

Shoulder pain is common and associated with substantial morbidity. Different treatment strategies are being prescribed with equivocal results. Virtual reality (VR) is a novel technology and emerging research suggests that VR may be a promising alternative to current treatments. Prior to effectiveness research or any large-scale introduction, VR-applications require appropriate scrutiny including feasibility- and acceptability of clinicians and patients. Therefore, the aim of this study was to collect experiences of physiotherapists after using immersive VR.

Methods

A qualitative interpretive design was used to explore physiotherapists' experiences related to the use of VR for people with shoulder symptoms. 17 physiotherapists were asked to use VR at home for five days prior to a focus group interview. Data from the focus group interviews were analyzed using a six-phase process of thematic analysis.

Results

Three main themes were identified, each divided into subthemes. The main themes were: 1. VR as an extension of contemporary physiotherapy care: physiotherapists were positive about the potential of VR and its applicability in daily care. 2. Physiotherapist uncertainties of future care using VR: participants expressed concerns about their professional identity, particularly as patients engage in independent home exercises. 3. Physiotherapist's requirements for implementation of VR: participants shared their needs for evidence regarding the effectiveness and parameters such as frequency, dosage and intensity of the VR intervention.

Conclusion

Physiotherapists were positive about VR as an intervention tool. However, they felt more knowledge is needed about parameters of VR. The findings of this study inform researchers and technology developers about optimal design of interventions and applications using VR.

Suprascapular Nerve Pulsed Radiofrequency as an Effective Pain Relief Strategy in Supraspinatus Muscle Tendon Tears

INTRODUCTION

The supraspinatus muscle tendon is the most frequently rotator cuff muscle torn. Reliable shoulder pain relief strategies are needed for patients with severe pain, refractory to conservative management, and without surgical indication.

MATERIALS AND METHODS

We conducted a retrospective analysis in a Portuguese reference Rehabilitation Centre during the 1st of January 2020 and the 30th of June 2021, including all patients with partial or complete supraspinatus tendon tear, older than 50 years, who presented with severe pain and who were submitted to suprascapular nerve pulsed radiofrequency.

RESULTS

We included 32 patients in our retrospective analysis, mainly female (53%) with a mean age of 66.50 years old. Most of the patients reported right shoulder pain (21 patients, 66%). The mean baseline pain, reported on the numeric rating scale, was 8.00 ± 0.88. Compared to baseline, mean pain reduced 4.00 ± 3.19 at three months (p<0.001), 3.59 ± 3.13 at six months (p<0.001) and 2.94 ± 2.78 at 12 months (p<0.001). From the 3rd to the 12th month there was an increase of 1.06 ± 2.77 in mean pain (p=0.038). There was no difference (p>0.05) in average pain at 0, 3, 6, or 12 months between patients who were simultaneously submitted to an intra-articular shoulder injection.

DISCUSSION

Our analysis revealed 36% average shoulder pain reduction for, at least, 12 months following suprascapular nerve pulsed radiofrequency, with a peak pain reduction of 50% at three months. Slow fading of pain reduction in the following nine months was seen, however, compared to baseline, pain reduction was always statistically significant. Cortico-anaesthetic intra-articular shoulder injections seem not to add benefit in shoulder pain reduction when performed simultaneously with suprascapular nerve pulsed radiofrequency.

CONCLUSION

Suprascapular nerve pulsed radiofrequency seems to be an effective strategy for shoulder pain reduction, in patients with severe pain, refractory to other management modalities. Nonetheless, larger prospective studies, analyzing shoulder functionality and quality of life lost scores, besides pain reduction, should be pursued.

Assessment of glenoid baseplate initial micromotion and fixation strength in reverse total shoulder arthroplasty designs using a direct shear force methodology

Background

In a reverse total shoulder arthroplasty, the altered glenohumeral joint center of rotation subjects the glenoid baseplate to increased shear forces and potential loosening.

Methods

This study examined glenoid baseplate micromotion and initial fixation strength with the application of direct shear force in a Sawbone model. The reverse total shoulder arthroplasty systems examined were the DJO Reverse® Shoulder Prosthesis, the Exactech Equinoxe® Reverse System, and the Tornier AequalisTM Reverse Shoulder Prosthesis. Specimens were cyclically tested with increasing shear loads until 150 µm of displacement between the implant and glenoid was achieved, and subsequently until failure, classified as either 1 cm of implant/glenoid displacement or fracture.

Results

The average load withstood for the 150 µm threshold for DJO, Tornier, and Exactech was 460 ± 88 N, 525 ± 100 N, and 585 ± 160 N, respectively. The average total load at device failure for DJO, Tornier, and Exactech was 980 ± 260 N, 1260 ± 120 N, and 1350 ± 230 N, respectively.

Discussion

The Exactech implant design trended toward requiring more load to induce micromotion at each threshold and to induce device failure, most commonly seen as inferior screw pull out. This study proposes design features that may enhance fixation and suggests little risk of initial micromotion or failure during initial post-operative recovery.

Alteration of muscle activity during voluntary rehabilitation training with single-joint Hybrid Assistive Limb (HAL) in patients with shoulder elevation dysfunction from cervical origin

Shoulder elevation, defined here as arm raising, being essential for activities of daily living, dysfunctions represent a substantial burden in patients' lives. Owing to the complexity of the shoulder joint, the tightly coordinated muscular activity is a fundamental component, and neuromuscular impairments have devastating effects. A single-joint shoulder type version of the Hybrid Assistive Limb (HAL) allowing motion assistance based on the intention of the user via myoelectric activation has recently been developed, and its safety was demonstrated for shoulder rehabilitation. Yet, little is known about the physiological effects of the device. This study aims to monitor the changes in muscle activity and motion during shoulder HAL rehabilitation in several patients suffering from shoulder elevation dysfunction from cervical radicular origin. 8 patients (6 males, 2 females, mean age 62.4 ± 9.3 years old) with weakness of the deltoid muscle resulting from a damage to the C5 nerve root underwent HAL-assisted rehabilitation. We combined surface electromyography and three-dimensional motion capture to record muscular activity and kinematics. All participants showed functional recovery, with improvements in their Manual Muscle Testing (MMT) scores and range of motion (ROM). During training, HAL decreased the activity of deltoid and trapezius, significantly more for the latter, as well as the coactivation of both muscles. We also report a reduction of the characteristic shrugging compensatory motion which is an obstacle to functional recovery. This reduction was notably demonstrated by a stronger reliance on the deltoid rather than the trapezius, indicating a muscle coordination tending toward a pattern similar to healthy individuals. Altogether, the results of the evaluation of motion and muscular changes hint toward a functional recovery in acute, and chronic shoulder impairments from cervical radicular origin following shoulder HAL rehabilitation training and provide information on the physiological effect of the device.

Digitally Assisted Versus Conventional Home-Based Rehabilitation After Arthroscopic Rotator Cuff Repair: A Randomized Controlled Trial

OBJECTIVE

The aim of this study was to evaluate the clinical impact of a 12-wk home-based digitally assisted rehabilitation program after arthroscopic rotator cuff repair against conventional home-based rehabilitation.

DESIGN

The digital therapy group performed independent technology-assisted sessions complemented with 13 face-to-face sessions, and the conventional therapy group had conventional face-to-face physical therapy (30 sessions). Primary outcome was functional change between baseline and 12 wks, measured through the Constant-Murley score. Secondary outcomes were the change in the QuickDASH Scale and shoulder range of motion.

RESULTS

Fifty participants enrolled; 41 completed the 12-wk program (23 digital therapy group vs. 18 conventional therapy group), and 32 (15 vs. 17) were available for the 12-mo follow-up assessment. No differences were found between groups regarding study endpoints at the end of the 12-wk program. However, follow-up results revealed the superiority of the digital therapy group for QuickDASH (P = 0.043), as well as an interaction between time and group in the Constant-Murley score (P = 0.047) in favor of the digital therapy group.

CONCLUSIONS

The results demonstrate that digital therapeutics can be used to achieve similar, if not superior, short- and long-term outcomes as conventional approaches after arthroscopic rotator cuff repair, while being far less human resource intensive than conventional care.Level of evidence: II.

Electromyographic Characteristics of a Single Motion Shoulder Exercise: A Pilot Study Investigating a Novel Shoulder Exercise

BACKGROUND

Shoulder exercises focused on strengthening the rotator cuff and scapular stabilizing muscles as well as addressing scapular dyskinesis and motor control have been shown to improve rotator cuff function and decrease shoulder pain. A single motion shoulder exercise that effectively activates the rotator cuff and scapular stabilizing muscles, engages the scapulohumeral rhythm, and includes eccentric contractions may be more effective and easier for patients to consistently perform as compared to multiple standard shoulder exercises.

PURPOSE

To compare the electromyographic muscle activation of key shoulder complex muscles during a single motion exercise and individual exercises (standard exercises) typically included in shoulder rehabilitation protocols.

STUDY DESIGN

Case-controlled, cohort study.

METHODS

Nineteen healthy men and women without shoulder pain or dysfunction were studied. Muscle activity of the rotator cuff and scapular stabilizing muscles (supraspinatus, infraspinatus, teres minor, trapezius [upper, middle and lower], serratus anterior, middle deltoid) was measured using surface EMG while subjects performed, in a standing position, several standard shoulder exercises typically included in shoulder rehabilitation protocols (resisted shoulder flexion, abduction in the scapular plane/scaption, external rotation, extension) and a single motion shoulder exercise consisting of a continuous movement creating the shape of "Figure of 8" in the transverse plane. The subjects used a weight between 5-15 pounds that produced muscle activation at 40-60% maximum voluntary isometric contraction (MVIC) for shoulder external rotation. That weight was then used for all of the exercises performed by the subject. The single highest EMG reading for each of the eight muscles studied, expressed as a percentage of MVIC, at any point during the second, third and fourth repetitions in a five repetition set was used to compare the single motion shoulder exercise and each exercise in the standard exercises set.

RESULTS

Ten men and nine women between 18-65 years of age were tested. No significant difference (p=.05) between the exercises was noted for the supraspinatus, infraspinatus, teres minor, serratus anterior, middle deltoid or upper trapezius. There was a significant difference favoring the standard exercises in the middle and lower trapezius. (p= 0.0109 and 0.0002 respectively).

CONCLUSION

In this pilot study, muscle activation during the single motion, Figure of 8 pattern exercise was not significantly different from the standard shoulder exercises in six of eight key muscles that are usually included in shoulder rehabilitation protocols. The exceptions were the middle and lower trapezius which were activated to a significantly higher degree with the standard exercises. Further evaluation of the clinical effectiveness of the single motion shoulder exercise is needed.

LEVEL OF EVIDENCE

Level 3b.

Diagnosis and Treatment of Snapping Scapula Syndrome: A Scoping Review

CONTEXT

Snapping scapula syndrome (SSS) is commonly misdiagnosed and underreported due to lack of awareness.

OBJECTIVE

This scoping review aims to summarize the current evidence related to SSS diagnosis and treatment to aid clinicians in managing the condition more effectively.

DATA SOURCES

PubMed, Medline, and Embase databases were searched for studies related to the etiology, diagnosis, or treatment of SSS (database inception to March 2020).

STUDY SELECTION

Databases were searched for available studies related to the etiology, diagnosis, or treatment of SSS.

STUDY DESIGN

A scoping review study design was selected to explore the breadth of knowledge in the literature regarding SSS diagnosis and treatment.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

Primary outcomes abstraction included accuracy of diagnostic tests, functional outcomes, and pain relief associated with various nonoperative and operative treatment options for SSS.

RESULTS

A total of 1442 references were screened and 40 met the inclusion criteria. Studies commonly reported SSS as a clinical diagnosis and relied heavily on a focused history and physical examination. The most common signs reported were medial scapular border tenderness, crepitus, and audible snapping. Three-dimensional computed tomography had high interrater reliability of 0.972, with a 100% success rate in identifying symptomatic incongruity of the scapular articular surface. Initial nonoperative treatment was reported as successful in most symptomatic patients, with improved visual analogue scale (VAS) scores (7.7 ± 0.5 pretreatment, to 2.4 ± 0.6). Persistently symptomatic patients underwent surgical intervention most commonly involving bursectomy, superomedial angle resection, or partial scapulectomy. High satisfaction rates of surgery were reported in VAS (6.9 ± 0.7 to 1.9 ± 0.9), American Shoulder and Elbow Surgeons scores (50.3 ± 12.2 to 80.6 ± 14.9), and mean simple shoulder test scores (5.6 ± 1.0 to 10.2 ± 1.1).

CONCLUSION

Focused history and physical examination is the most crucial initial step in the diagnostic process, with supplemental imaging used to assess for structural etiologies when nonoperative management fails. Nonoperative management is as effective as surgical management in pain relief and is advised for 3 to 6 months before operative treatment.

Stiffness after arthroscopic rotator cuff repair: a rehabilitation problem or a surgical indication?

Hypothesis

The purpose of this study was to determine the incidence of clinically significant postoperative stiffness after arthroscopic rotator cuff repair and its resolution. The study also sought to determine clinical and surgical factors that may be associated with increased rates of postoperative stiffness.

Methods

We conducted a level III retrospective review of a consecutive series of arthroscopic rotator cuff repairs. During a 5-year period, the senior author (C.J.R.) performed 150 arthroscopic rotator cuff repairs at our institution. Demographic data, comorbid medical conditions, descriptions of rotator cuff tears (including size and level of retraction), and concomitant surgical procedures were evaluated on their correlation with stiffness. All office visits were reviewed to determine preoperative and postoperative motion. Patients were followed up at 1 week, 3 weeks, 6-8 weeks, 3 months, about 6 months, and 1 year postoperatively.

Results

In our analysis of tear types, we were unable to associate stiffness with the type of tear, the tendon torn, or the number of tendons torn or with whether the tendons were retracted. However, we were able to associate female sex, workers' compensation insurance, and a concomitant biceps procedure with stiffness at several time points. The incidence of stiffness was highest at 12 weeks, with 7.3% of patients presenting with stiffness. The rate of stiffness decreased with continued follow-up. Stiffness was found in 3.3% of patients at 16-24 weeks and in 1.6% of patients at 1 year.

Conclusions

Prolonged physical therapy will result in resolution of stiffness in the vast majority of cases, often obviating the return to the operating room for capsular release and lysis of adhesions or mobilization under anesthesia.

Implementation of interactive games to a shoulder rehabilitation and evaluation system

BACKGROUND

After an operation, the shoulder and wrist might not be able to lift and swing freely, and must be assisted with rehabilitation training.

OBJECTIVE

In this paper, Kinect combined with multiple sensors of a Bluetooth ball is proposed to improve the measurement function of the arm's micro-motion trajectory, rotation amount, and acceleration, which cannot be detected by Kinect alone.

METHODS

We designed two virtual scene rehabilitation games for clinical trials. We performed validity analysis with a paired sample t-test.

RESULTS

A significance value of P*< 1 was obtained, and the arm lift angle shows an improvement from 30∘ to 60∘, indicating that the range of motion of the hand and shoulder is gradually improving.

CONCLUSION

Experiments show that virtual games combined with multiple sensors can better understand the patient's rehabilitation situation.

Interactive design of patient-oriented video-games for rehabilitation: concept and application

PURPOSE

Serious video-games are innovative tools used to train the motor skills of subjects affected by neurological disorders. They are often developed to train a specific type of patients and the rules of the game are standardly defined. A system that allows the therapist to design highly patient-oriented video-games, without specific informatics skills, is proposed.

METHOD

The system consists of one personal computer, two screens, a Kinect™ sensor and a specific software developed here for the design of the video-games. It was tested with the collaboration of three therapists and six patients, and two questionnaires were filled in by each patient to evaluate the appreciation of the rehabilitative sessions.

RESULTS

The therapists learned easily how to use the system, and no serious difficulties were encountered by the patients. The questionnaires showed an overall good satisfaction by the patients and highlighted the key-role of the therapist in involving the patients during the rehabilitative session.

CONCLUSIONS

It was found that the proposed system is effective for developing patient-oriented video-games for rehabilitation. The two main advantages are that the therapist is allowed to (i) develop personalized video-games without informatics skills and (ii) adapt the game settings to patients affected by different pathologies. Implications for rehabilitation Virtual reality and serious video games offer the opportunity to transform the traditional therapy into a more pleasant experience, allowing patients to train their motor and cognitive skills. Both the therapists and the patients should be involved in the development of rehabilitative solutions to be highly patient-oriented. A system for the design of rehabilitative games by the therapist is described and the feedback of three therapists and six patients is reported.

Electromyographic Activity of Scapular Muscle Control in Free-Motion Exercise

CONTEXT

The appropriate resistance intensity to prescribe for shoulder rehabilitative exercise is not completely known. Excessive activation of the deltoid and upper trapezius muscles could be counterproductive for scapulohumeral rhythm during humeral elevation.

OBJECTIVE

To identify the effects of different exercise intensities on the scapular muscles during a free-motion "robbery" exercise performed in different degrees of shoulder abduction in seated and standing positions.

DESIGN

Descriptive laboratory study.

SETTING

Kinesiology Adapted Physical Education Laboratory.

PATIENTS OR OTHER PARTICIPANTS

A total of 15 healthy male college students (age = 20.5 ± 2.2 years, height = 174.5 ± 5.3 cm, mass = 63.8 ± 6.0 kg).

INTERVENTION(S)

Participants performed 5 repetitions of a randomized exercise sequence of the robbery exercise in 2 body positions (seated, standing), 2 shoulder-abducted positions (W [20°], 90/90 [90°]) at 3 intensities (0%, 3%, and 7% body weight).

MAIN OUTCOME MEASURE(S)

Electromyographic (EMG) activity of the upper trapezius, lower trapezius, serratus anterior, anterior deltoid, and infraspinatus muscles of the upper extremity was collected. All EMG activities were normalized by the maximal voluntary isometric contraction of each corresponding muscle (%).

RESULTS

The serratus anterior, anterior deltoid, and infraspinatus EMG activities were greater at 7% body weight in the seated position compared with the standing position (P < .05). The EMG activities in all 5 muscles were greater in the 90/90 position than in the W position (P < .05).

CONCLUSIONS

Scapular muscle activity modulated relative to changes in body posture and resistance intensity. These findings will enable clinicians to prescribe the appropriate level of exercise intensity and positioning during shoulder rehabilitation.

POSTERIOR STERNOCLAVICULAR JOINT DISLOCATION IN A DIVISION I FOOTBALL PLAYER: A CASE REPORT

Posterior dislocation of the sterno-clavicular (SC) joint is a rare injury in athletes. It normally occurs in high collision sports such as American football or rugby. Acute posterior dislocations of the SC joint can be life-threatening as the posteriorly displaced clavicle can cause damage to vital vascular and respiratory structures such as the aortic arch, the carotid and subclavian arteries, and the trachea. The potential severity of a posterior SC joint dislocation provides multiple challenges for clinicians involved in the emergency care and treatment of this condition. Integration of clinical examination observations, rapid critical thinking, and appropriate diagnostic imaging are often required to provide the best management and outcome for the injured athlete. The criterion for return-to-play and participation in collision sports after suffering a posterior dislocation of the SC joint are unclear due to the rarity of this injury. The purpose of this case report is to describe the management, from the initial on-field evaluation through the return-to-sport, of a collegiate Division I football player following a traumatic sports-related posterior SC joint dislocation. The rehabilitation process and the progression to return to participation are also presented and briefly discussed.

LEVEL OF EVIDENCE

4-Single case report.

Muscle activity pattern of the shoulder external rotators differs in adduction and abduction: an analysis using positron emission tomography

BACKGROUND

The muscle activity pattern during shoulder external rotation has not been fully clarified. This study aimed to determine the activities involved in external rotation in the adducted and abducted positions using positron emission tomography (PET).

METHODS

Seven healthy volunteers underwent PET examinations after performing external rotation using an elastic band at both 0° and 90° of shoulder abduction in the frontal plane. External rotation exercise was performed before and after injection of fluorine 18 fluorodeoxyglucose, which was followed by PET examination. The protocols for external rotation exercise were identical between the 2 shoulder positions. To obtain control data, PET examination was also performed under resting conditions. The order of these 3 PET examinations was randomized, and they were performed at intervals of 1 week or greater. Each PET image was fused to the corresponding magnetic resonance image to identify each shoulder muscle. After this, the standardized uptake value was calculated in each muscle and was compared between the 2 shoulder positions.

RESULTS

The infraspinatus showed the greatest muscle activity during external rotation at 0° of abduction, whereas the teres minor showed the greatest activity at 90° of abduction. The teres minor-infraspinatus ratio at 90° of abduction (mean ± SD, 1.21 ± 0.23) was significantly higher than that at 0° of abduction (0.84 ± 0.15) (P < .01).

CONCLUSION

The infraspinatus and teres minor are the main shoulder external rotators. The teres minor is more important as an external rotator in abduction than in adduction.

A criterion based sling weaning progression (sweap) and outcomes following shoulder arthroscopic surgery in an active duty military population

INTRODUCTION

Little objective evidence is available to guide rehabilitation protocols in regard to the sling weaning process following arthroscopy surgery of the shoulder. The purpose of this study was to establish an objective, criterion based protocol for accelerated sling weaning following shoulder arthroscopy.

METHODS

82 active duty service members (ADSM) underwent elective shoulder arthroscopic surgery by three orthopaedic staff surgeons. One physical therapist progressed patients through the criterion based sling weaning progression (SWEAP) protocol for each surgery and documented pain levels, sleep habits, and decrease in sling use. Preoperative and six month postoperative Quick Disability of the Arm, Shoulder, and Hand (qDASH) and Shoulder Pain and Disability Index (SPADI) scores were obtained. The ability to perform an Army Physical Fitness Test (APFT) was recorded at six months postoperative.

RESULTS

Patients completed sling weaning at an overall mean of 16.6 ± 5.0 days with continued use in unprotected military settings only beyond this timeframe. As patients steadily progressed out of the sling for 1 hour, 2-3 hours, and half-day periods, average pain scores decreased during these time periods at 5.0±1.2, 3.7±1.2, and 2.1±1.3 (0-10 pain scale), respectively. Patients obtained 6-7 hours of sleep or normal sleep habits at an average of 10.9±4.4 days postoperative. Overall, preoperative qDASH and SPADI scores improved from 39.8±13.0 to 2.4±2.0 and 46.4±16.1 to 3.3±3.2, respectively, at 6 months follow up. All 82 patients were able to return to deployable status. 30 (36.6%) patients required formal restrictions for the push-up portion of the APFT at six months postoperative. 7 of these 30 patients required running restrictions.

CONCLUSIONS

Early improvement in quality of life indicators can be obtained in the initial postoperative period with a progressive, criterion based SWEAP protocol. Patients demonstrated favorable outcomes with return to occupational and physical fitness activities. This study will guide orthopedic surgeons and physical therapists to enhance the sling weaning process during rehabilitation protocols and improve preoperative counseling sessions for accurate postoperative expectations.

STUDY DESIGN

Retrospective Case Series; Level of evidence 4.

The role of the scapula

Previously, the scapular musculature was often neglected in designing a rehabilitation protocol for the shoulder. In the past two decades a significant amount of research has been performed in order to help identify the role of the scapula in upper extremity function. Weakness of the scapular stabilizers and resultant altered biomechanics could result in: 1) abnormal stresses to the anterior capsular structures of the shoulder, 2) increased possibility of rotator cuff compression, and 3) decreased shoulder complex neuromuscular performance. This clinical commentary presents facts about the anatomy and biomechanics of the scapula and surrounding musculature, and describes the pathomechanics of scapular dysfunction. The focus is upon the assessment of dysfunction and retraining of the scapular musculature.

LEVEL OF EVIDENCE

5.

The role of the scapula in the rehabilitation of shoulder injuries

OBJECTIVE

To present a clinical understanding of the role the scapula plays in the mechanics of shoulder function and specialized techniques for the rehabilitation of injuries around the shoulder girdle.

BACKGROUND

The scapular musculature is often neglected in the evaluation and treatment of shoulder injuries. This lack of attention often degenerates into the incomplete evaluation and rehabilitation of scapular dysfunction. Dysfunction or weakness of the scapular stabilizers often results in altered biomechanics of the shoulder girdle. The altered biomechanics can result in (1) abnormal stresses to the anterior capsular structures, (2) the increased possibility of rotator cuff compression, and (3) decreased performance.

DESCRIPTION

We review the anatomy and role of the scapula, the pathomechanics of injury and dysfunction, and the evaluation and rehabilitation of the scapula. CLINICAL ADVANTAGE: Knowledge of how the scapular muscles influence function at the shoulder builds a strong foundation for the clinician to develop rehabilitation programs for the shoulder.