Scapular Winging: A Great Masquerader of Shoulder Disorders: AAOS Exhibit Selection

Upper limb modeling and motion extraction based on multi-space-fusion

Modeling and motion extraction of human upper limbs are essential for interpreting the natural behavior of upper limb. Owing to the high degrees of freedom (DOF) and highly dynamic nature, existing upper limb modeling methods have limited applications. This study proposes a generic modeling and motion extraction method, named Primitive-Based triangular body segment method (P-BTBS), which follows the physiology of upper limbs, allows high accuracy of motion angles, and describes upper-limb motions with high accuracy. For utilizing the upper-limb modular motion model, the motion angles and bones can be selected as per the research topics (The generic nature of the study targets). Additionally, P-BTBS is suitable in most scenarios for estimating spatial coordinates (The generic nature of equipment and technology). Experiments in continuous motions with seven DOFs and upper-limb motion description validated the excellent performance and robustness of P-BTBS in extracting motion information and describing upper-limb motions, respectively. P-BTBS provides a new perspective and mathematical tool for human understanding and exploration of upper-limb motions, which theoretically supports upper-limb research.

Treatment of neurogenic scapular winging: a systematic review on outcomes after nonsurgical management and tendon transfer surgery

BACKGROUND

Scapular winging is a rare condition of the shoulder girdle that presents challenging treatment decisions for clinicians. To inform clinical practice, clinicians need guidance on what the best treatment decision is for their patients, and such recommendations should be based on the total evidence available. Therefore, the purpose of this review was to systematically review the evidence regarding nonsurgical management and tendon transfer surgery of patients with neurologic scapular winging due to serratus anterior (SA) or trapezius (TP) palsy.

METHODS

PubMed, Embase, Web of Science, Cochrane Library, Emcare, and Academic Search Premier were searched up to April 5, 2022, for studies reporting on clinical outcomes after nonsurgical management and tendon transfer surgery of scapular winging due to weakness of the SA or TP muscle. The Integrated quality Criteria for Review Of Multiple Study (ICROMS) tool was used to classify the quality of the studies. Primary outcomes were the fraction of patients with spontaneous recovery after nonsurgical management and improvement in shoulder function, pain scores, and shoulder scores after tendon transfer surgery. Data were pooled if data on the same outcome were available for at least 3 studies, using random-effects meta-analysis.

RESULTS

Twenty-three (10 moderate-quality [MQ] and 13 low-quality) studies were included. Six studies (3 MQ; 234 shoulders) reported on outcomes after nonsurgical management of SA palsy, whereas 12 (6 MQ; 221 shoulders) and 6 studies (1 MQ; 80 shoulders) evaluated the outcomes of tendon transfer for SA or TP palsy (1 study addressed both). Spontaneous recovery of scapular winging with nonsurgical management varied between 21% and 78% across studies after a median follow-up of 72 months. For surgical management of SA palsy, pooling data in a meta-analysis showed that patients on average improved by 47° (95% confidence interval [CI]: 34-61, P ≤ .001) in active forward flexion, had lower visual analog scale scores for pain (mean difference [MD]: -3.0, 95% CI: -4.9 to -1.0, P = .003), and had substantial improvements in American Shoulder and Elbow Surgeons (MD: 24, 95% CI: 9-39, P = .002) and Constant scores (MD: 45, 95% CI: 39-51, P ≤ .001). Patients with TP palsy on average improved by 36° (95% CI: 21-51, P ≤ .001) in active forward flexion after tendon transfer. Statistical pooling was not possible for other outcome measures as insufficient data were available.

CONCLUSION

A substantial part of nonsurgically managed patients with scapular winging seem to have persistent complaints, which should be part of the information provided to patients. Data pooling demonstrated significant improvements in shoulder function, pain scores, and shoulder scores after tendon transfer surgery, but higher quality evidence is needed to allow for more robust recommendations and guide clinical decision-making on when to perform such functional surgery.

Comparison of the Effects of Isometric Horizontal Abduction on Shoulder Muscle Activity During Wall Push-Up Plus and Wall Slide in Individuals With Scapular Winging

CONTEXT

Wall push-up plus (WPP) and wall slide (WS) are commonly prescribed in early rehabilitation to increase serratus anterior (SA) muscle activity. For individuals with scapular winging (SW), synergistic muscles such as upper trapezius (UT) and pectoralis major (PM) may compensate for weak SA during scapular movement. However, no studies have applied isometric horizontal abduction (IHA) during WS in individuals with SW nor have compared it with WPP with IHA.

OBJECTIVES

This study compared the effects of IHA on shoulder muscle activity during WPP and WS exercises in individuals with SW.

DESIGN

Cross-sectional study; 2-way repeated-measures analysis of variance was used to assess the statistical significance of observed differences in SA, UT, PM, lower trapezius (LT), and infraspinatus (IS) muscle activities.

SETTING

Research laboratory.

PATIENTS

We recruited 30 individuals with SW comprising 20 men and 10 women.

INTERVENTIONS

The individuals performed WPP and WS exercises with and without IHA using Thera-Band.

MAIN OUTCOME MEASURES

Surface electromyography was used to measure muscle activity of the SA, UT, PM, LT, and IS during the isometric phase of WPP and WS. Maximal voluntary isometric contractions were recorded to normalize electromyographic data.

RESULTS

There was no significant interaction between IHA application and exercise type for any of the shoulder muscles. IHA application increased SA (P = .008), UT (P = .001), LT (P = .009), and IS (P = .000) activities and decreased PM (P = .001) activity compared with those without IHA. WS exercises elicited higher PM (P = .017) and LT (P = .011) activities than WPP.

CONCLUSION

WPP and WS with IHA may be effective in increasing the muscle activities of shoulder stabilizers and preventing overactivation of PM activity. WPP may be recommended for individuals with overactivated PM, whereas WS may be used to increase LT activity.

Pectoralis minor syndrome - review of pathoanatomy, diagnosis, and management of the primary cause of neurogenic thoracic outlet syndrome

Thoracic outlet syndrome is an umbrella term for compressive pathologies in the supraclavicular and infraclavicular fossae, with the vast majority being neurogenic in nature. These compressive neuropathies, such as pectoralis minor syndrome, can be challenging problems for both patients and physicians. Robust understanding of thoracic outlet anatomy and scapulothoracic biomechanics are necessary to distinguish neurogenic vs. vascular disorders and properly diagnose affected patients. Repetitive overhead activity, particularly when combined with scapular dyskinesia, leads to pectoralis minor shortening, decreased volume of the retropectoralis minor space, and subsequent brachial plexus compression causing neurogenic thoracic outlet syndrome. Combining a thorough history, physical examination, and diagnostic modalities including ultrasound-guided injections are necessary to arrive at the correct diagnosis. Rigorous attention must be paid to rule out alternate etiologies such as peripheral neuropathies, vascular disorders, cervical radiculopathy, and space-occupying lesions. Initial nonoperative treatment with pectoralis minor stretching, as well as periscapular and postural retraining, is successful in the majority of patients. For patients that fail nonoperative management, surgical release of the pectoralis minor may be performed through a variety of approaches. Both open and arthroscopic pectoralis minor release may be performed safely with effective resolution of neurogenic symptoms. When further indicated by the preoperative workup, this can be combined with suprascapular nerve release and brachial plexus neurolysis for complete infraclavicular thoracic outlet decompression.

Muscle Tendon Transfers Around the Shoulder: Diagnosis, Treatment, Surgical Techniques, and Outcomes

➤

Muscle tendon transfers (MTTs) are effective surgical procedures for reducing pain and for improving active shoulder range of motion and patient-reported outcomes for a wide range of pathologies, including serratus anterior and trapezius muscle palsy, irreparable subscapularis tears, irreparable posterosuperior rotator cuff tears, irreparable posterior rotator cuff tears in the setting of reverse shoulder arthroplasty, and symptomatic complete deltoid deficiency.

➤

The principles of MTT include ensuring that the transferred muscle is expendable, the muscle tendon unit has similar excursion, the line of pull of the transferred tendon and of the recipient muscle are similar in terms of biomechanical force, and the transferred muscle should replace at least 1 grade of strength of the deficient recipient muscle.

➤

When MTT procedures are considered, patients must have exhausted all nonoperative management, have preserved passive range of motion, and have an understanding of the postoperative expectations and potential complications.

➤

For patients with scapulothoracic abnormal motion (STAM) due to long thoracic nerve palsy, the indirect or direct pectoralis major tendon transfer is an effective procedure for reducing pain and improving active forward elevation. For patients with STAM due to spinal accessory nerve palsy, the Eden-Lange or the triple tendon transfer procedures reduce pain and improve active forward elevation and abduction as well as patient-reported clinical outcomes.

➤

Both pectoralis major and latissimus dorsi transfer procedures for isolated irreparable subscapularis deficiency without anterosuperior humeral head escape result in improvement with respect to pain, patient-reported outcomes, and forward elevation, with the pectoralis major tendon transfer demonstrating durable long-term outcomes.

➤

The latissimus dorsi or lower trapezius tendon transfer procedures for irreparable posterosuperior rotator cuff tears reliably improve patient-reported outcomes, forward elevation, abduction, and external rotation range of motion. Additionally, latissimus dorsi transfer with or without teres major transfer can be used to restore active external rotation, both in the native shoulder and in the setting of reverse shoulder arthroplasty.

➤

The complications of MTTs include infection, hematoma, and failure of tendon transfer healing; therefore, it is recommended that these complex procedures be performed by shoulder surgeons with appropriate training.

Diagnosis and epidemiology of winged scapula in breast cancer patients: A systematic review and meta-analysis

BACKGROUND

Winged scapula (WS) is a critical complication of axillary surgery in patients treated for breast cancer, and is associated with pain, impairment of the upper extremity's function and poor performance in daily activities.

SOURCES OF DATA

A systematic review and meta-analysis were performed following the PRISMA guidelines. Two independent reviewers searched PubMed, Embase and Virtual Health Library databases from January 1, 2000 to December 1, 2020. Clinical studies evaluating the diagnosis and epidemiology of WS among breast cancer surgery (BCS) patients were included.

AREAS OF AGREEMENT

The diagnosis of WS relies almost entirely on physical assessment. Studies have suggested a high variability in the report of the incidence of WS given the subjectivity of its diagnosis, and the different criteria used during clinical assessment.

AREAS OF CONTROVERSY

The diagnosis of WS in BCS patients remains a challenge given the lack of standardized diagnostic protocols. Physical examination cannot rely on one manoeuvre only, as it may overlook patients with subtle injuries or overweight and contributing to the underreporting of its incidence.

GROWING POINTS

BCS patients undergoing axillary lymph node dissection experience a significantly higher incidence of WS than those undergoing sentinel lymph node dissection. The global incidence of WS after BCS is 16.79%. Additionally, the anterior flexion test and the push-up test are the most commonly performed diagnostic manoeuvers.

AREAS TIMELY FOR DEVELOPING RESEARCH

Further studies should aim for objective diagnostic tests, especially when the condition is not evident.

Comparison of ultrasound with electrodiagnosis of scapular winging: A prospective case control study

OBJECTIVE

Compare high-resolution ultrasound (HRUS) and electrodiagnostic examination (EDX) in the diagnostic workup of patients with scapulae alatae.

METHODS

27 patients with scapulae alatae and 41 healthy subjects (HS) and underwent a standardized clinical examination (CEX), EDX and HRUS. We measured the thickness of the serratus anterior (SER), rhomboid major and trapezius muscles and the diameter of the long thoracic (LTN), dorsal scapular and spinal accessory nerves (SAN).

RESULTS

Twenty patients showed medial winging and six patients showed lateral winging on CEX. One patient had both lateral and medial winging. In patients with medial winging, the SER muscle was thinner and the LTN diameter was larger on the symptomatic side compared with the asymptomatic side and with the dominant side in HS. In this group, both EDX and HRUS detected abnormalities of SER muscle/ LTN with sensitivity of 65%, and with specificity of 100% and 57%, respectively. EDX and HRUS detected abnormalities of the trapezius muscle/ SAN with sensitivity of 60% and 40%, and specificity of 91%, and 86 % a, respectively. There was no significant difference between the two methods.

CONCLUSION

HRUS can contribute to the diagnostic workup of scapulae alatae by demonstrating atrophy of muscles and enlargement in nerve diameter.

SIGNIFICANCE

HRUS supplements EDX in the diagnostic workup of scapulae alatae.

Voluntary winging of the scapula: Proposed diagnostic criteria

We report a series of 10 patients with unilateral, dynamic, winged scapula (WS), without cause, that was diagnosed as voluntary winging of the scapula (VWS). We compared clinical, electrodiagnostic, and other examination data for 10 patients with VWS and 146 with dynamic WS-related neuromuscular disorders, to establish a detailed pattern of the VWS subtype. In VWS, electrodiagnostic and other examinations did not reveal any neuromuscular or orthopedic cause. Winging was dynamic, obvious, neither medial nor lateral, and mainly involved the inferior angle of the scapula, in young patients. VWS never appeared during floor push-ups. Patients could produce WS at will with the index and healthy shoulder, between 25° and 65° of anterior elevation, or with shoulder internal rotation. VWS is a benign disorder that can be distinguished from neuromuscular WS by normal electrodiagnostic results for muscles and nerves of both shoulders and two specific clinical tests.

New insights into pathways of the dorsal scapular nerve and artery for selective dorsal scapular nerve blockade

Background

The aim of this study was to clarify the topographical relationships between the dorsal scapular nerve (DSN) and the dorsal scapular artery (DSA) in the interscapular region to identify safe and convenient injection points related to DSN blockade.

Methods

Thirty shoulders of embalmed Korean cadavers and 50 live subjects were used for dissection and ultrasound (US) analysis.

Results

The running patterns of the DSA and DSN in the interscapular region were classified into 3 types. Type I was defined as nerves that were medial to the artery and parallel without changing location (80.0% of specimens). In type II (13.3%), the nerve and artery traversed one another only one time over their entire length. In type III (6.7%), the nerve and artery traversed one another, resembling a twist. Above the level of the scapular spine, the nerve was always medial to the artery. Below the scapular spine, the number of arteries was obviously decreased. Most of the arteries were lateral to the medial border of the scapula, except at the level of the superior angle of the scapula artery (SA). The positional tendency of the DSN toward the medial or lateral sides from the medial border of the scapula was similar. In US imaging of live subjects, the DSA was most observed at the level of the SA (94.0%).

Conclusions

Results of this study enhance the current knowledge regarding the pathway of the DSN and DSA and provide helpful information for selective diagnostic nerve blocks in the interscapular region.

Scapular winging on Exercise Cambrian Patrol: three soldiers in three days - an occupational risk?

Exercise CAMBRIAN PATROL is an internationally recognised, arduous patrolling exercise held annually in Mid-South Wales. The 2017 iteration of the exercise generated three uncommon shoulder injuries in three consecutive days, all of which were thought to have a similar aetiology. This article presents a case series of three instances of scapular winging in soldiers carrying heavy weight. We review the relevant anatomy and pathophysiology of long thoracic nerve injury and discuss management strategies of scapular winging. Occupational health considerations are reviewed, with respect to carrying large amounts of weight over distance and difficult terrain within the armed forces, along with discussion of a novel weight distribution system (VIRTUS) which has recently been brought into service by the British Army.

Nerves Around the Shoulder: What the Radiologist Should Know?

Peripheral neuropathies of the shoulder are common and could be related to traumatic injury, shoulder surgery, infection or tumour but usually they result from an entrapment syndrome. Imaging plays an important role to detect the underlying causes, to assess the precise topography and the severity of nerve damage. The key points concerning the imaging of nerve entrapment syndrome are the knowledge of the particular topography of the injured nerve, and the morphology as well signal modifications of the corresponding muscles. Magnetic Resonance Imaging best shows these findings, although Ultrasounds and Computed Tomography sometimes allow the diagnosis of neuropathy.

[Winged scapula in lyme borreliosis]

Here we present the case of a young patient with one-sided winged scapula and lyme borreliosis. This disease can be very delimitating in daily life. If non-operative treatment fails, dynamic or static stabilization of the scapula can be a therapeutic option.

Isolated Peripheral Nerve Palsies in Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) poses a difficult diagnostic entity with varied etiology and clinical presentation. We present a 35-year-old gentleman with unilateral long thoracic nerve palsy and contralateral subscapular paralysis caused by aberrant scalenus medius anatomy. TOS ought to be considered in patients presenting with isolated nerve palsies.

Neuromuscular ultrasound for evaluation of scapular winging

INTRODUCTION

Clinicians who treat nerve and muscle disorders may be asked to evaluate patients who have unilateral or bilateral scapular winging. Traditionally, this evaluation has relied upon a thorough history, physical examination, and electrodiagnostic testing to localize the cause of winging and detect the underlying neuromuscular pathology. Neuromuscular ultrasound has emerged as a non-invasive technique that can be used for structural evaluation of nerve and muscle abnormalities.

METHODS

Previous studies of imaging in scapular winging and experiences from our diagnostic laboratory are reviewed.

RESULTS

Four standard and 4 ancillary ultrasound views are described for evaluation of scapular winging.

CONCLUSION

Ultrasound is a non-invasive, painless, and radiation-free technology that can be used to evaluate scapular winging. Muscle Nerve 56: 7-14, 2017.

Validity of a shoulder-specific quality of life questionnaire, the Western Ontario Rotator Cuff Index, for patients with scapula alata

BACKGROUND

No validated shoulder-specific quality of life measurements exist for patients with scapula alata (SA). The objective was to investigate the content validity of the Western Ontario Rotator Cuff (WORC) Index for SA patients.

METHODS

Content validity was evaluated by an expert panel of medical doctors and physiotherapists (n = 6) and a sample of SA patients (n = 44). The Content Validity Index (CVI) and a modified kappa index (κ*) assessed the relevance of WORC Index.

RESULTS

The experts evaluated ten of 21 items as excellent for content validity (I-CVI > 0.78, κ* > 0.74), five items as fair (I-CVI < 0.78, 0.40 < κ* < 0.60), and six were considered content invalid (I-CVI < 0.78, κ* < 0.40). The average scale (S-CVI/Ave) for the entire WORC Index was 0.72.The SA patients evaluated four of 21 items as excellent for content validity (I-CVI > 0.78, κ* > 0.74), nine items as good (I-CVI < 0.78, 0.60 > κ* < 0.74), six as fair (I-CVI < 0.78, 0.40 < κ* < 0.59) and two were considered content invalid (I-CVI < 0.78, κ* < 0.40). The S-CVI/Ave was 0.56.

CONCLUSION

This study is the first step evaluating content validity in the WORC Index for SA patients. The results indicated that half of the 21 items had excellent or good content validity. Several items need to be discussed by an SA team aiming to find consensus for changing or removing, leaving the possibility to develop a new quality of life measure, the first for SA patients.

Reproducibility of isometric shoulder protraction and retraction strength measurements in normal subjects and individuals with winged scapula

BACKGROUND

The strength of the shoulder protractors and retractors may be compromised in individuals with winged scapula (IwWS). However, no standard approach to measuring the strength of these muscles has been described. The aim of this study was to study the intra-rater and inter-rater reproducibility of a fixed-base isometric dynamometer and to describe cutoff scores for clinically meaningful change for protraction and retraction isometric strength.

METHOD

Twice during a week, 20 normal subjects and 20 IwWS were tested by 2 independent raters.

RESULTS

IwWS were significantly weaker (P < .001) than control subjects in their protraction and retraction isometric strength. Excellent intra-rater and inter-rater correlations were obtained in most combinations, leading to low cutoff scores for meaningful change expressed in terms of the smallest real difference.

CONCLUSION

When it is properly used, the technique described in this paper is recommended as an effective clinical tool for the quantitative assessment of protraction and retraction isometric strength, both for status determination and for monitoring of change in IwWS during and after rehabilitation.

Scapular and Shoulder Girdle Muscular Anatomy: Its Role in Periscapular Tendon Transfers

The importance of coordinated, normal scapulothoracic motion in facilitating full, pain-free motion of the shoulder complex has been increasingly studied over the past decade, leading to renewed interest in scapular-based reconstructions to improve shoulder girdle motion through the use of muscle advancements and tendon transfers. This article will review recent advances regarding scapulothoracic motion and the muscular stabilizers of the scapula, focusing on clinical diagnosis and anatomy as it pertains to scapular dyskinesis and common periscapular tendon transfers. Although many of these treatment techniques remain in their infancy and further follow-up is necessary before universal adoption, they provide a novel means of addressing difficult-to-treat and complex shoulder girdle pathologies.

A Biomechanical Model of the Scapulothoracic Joint to Accurately Capture Scapular Kinematics during Shoulder Movements

The complexity of shoulder mechanics combined with the movement of skin relative to the scapula makes it difficult to measure shoulder kinematics with sufficient accuracy to distinguish between symptomatic and asymptomatic individuals. Multibody skeletal models can improve motion capture accuracy by reducing the space of possible joint movements, and models are used widely to improve measurement of lower limb kinematics. In this study, we developed a rigid-body model of a scapulothoracic joint to describe the kinematics of the scapula relative to the thorax. This model describes scapular kinematics with four degrees of freedom: 1) elevation and 2) abduction of the scapula on an ellipsoidal thoracic surface, 3) upward rotation of the scapula normal to the thoracic surface, and 4) internal rotation of the scapula to lift the medial border of the scapula off the surface of the thorax. The surface dimensions and joint axes can be customized to match an individual’s anthropometry. We compared the model to “gold standard” bone-pin kinematics collected during three shoulder tasks and found modeled scapular kinematics to be accurate to within 2mm root-mean-squared error for individual bone-pin markers across all markers and movement tasks. As an additional test, we added random and systematic noise to the bone-pin marker data and found that the model reduced kinematic variability due to noise by 65% compared to Euler angles computed without the model. Our scapulothoracic joint model can be used for inverse and forward dynamics analyses and to compute joint reaction loads. The computational performance of the scapulothoracic joint model is well suited for real-time applications; it is freely available for use with OpenSim 3.2, and is customizable and usable with other OpenSim models.

An unusual cause of subacromial impingement after traumatic intrathoracic displacement of the scapula

Intrathoracic displacement of the scapula is a rare injury, with only five cases reported in the literature. They usually occur following high-energy accidents, often involving a motor vehicle. We report a case of a 50-year-old woman who presented with symptoms of subacromial impingement 31 years ago after a road traffic accident, which resulted in multiple fractures and malunion of the fourth and fifth ribs posteriorly; this incident resulted in displacement of the inferior tip of the scapula between the malunited ribs. Scapula-thoracic dyskinesis as a result of this injury led to symptoms of subacromial impingement.

Effect of scapular dyskinesis on supraspinatus repair healing in a rat model

BACKGROUND

Rotator cuff tears are common conditions that often require surgical repair to improve function and to relieve pain. Unfortunately, repair failure remains a common problem after rotator cuff repair surgery. Several factors may contribute to repair failure, including age, tear size, and time from injury. However, the mechanical mechanisms resulting in repair failure are not well understood, making clinical management difficult. Specifically, altered scapular motion (termed scapular dyskinesis) may be one important and modifiable factor contributing to the risk of repair failure. Therefore, the objective of this study was to determine the effect of scapular dyskinesis on supraspinatus tendon healing after repair.

METHODS

A rat model of scapular dyskinesis was used. Seventy adult male Sprague-Dawley rats (400-450 g) were randomized into 2 groups: nerve transection of the accessory and long thoracic nerves (SD) or sham nerve transection (Sham control). After this procedure, all rats underwent unilateral detachment and repair of the supraspinatus tendon. All rats were sacrificed at 2, 4, and 8 weeks after surgery. Shoulder function, passive joint mechanics, and tendon properties (mechanical, histologic, organizational, and compositional) were evaluated.

RESULTS

Scapular dyskinesis alters joint function and may lead to compromised supraspinatus tendon properties. Specifically, diminished mechanical properties, altered histology, and decreased tendon organization were observed for some parameters.

CONCLUSION

This study identifies scapular dyskinesis as one underlying mechanism leading to compromise of supraspinatus healing after repair. Identifying modifiable factors that lead to compromised tendon healing will help improve clinical outcomes after repair.

Surgical Correction of Posttraumatic Scapulothoracic Bursitis, Rhomboid Major Muscle Injury, Ipsilateral Glenohumeral Instability, and Headaches Resulting from Circus Acrobatic Maneuvers

We report the case of a 28-year-old transgender (male-to-female) patient that had a partial tear of the rhomboid major tendon, scapulothoracic bursitis, and glenohumeral instability on the same side. These conditions resulted from traumatic events during circus acrobatic maneuvers. Additional aspects of this case that make it unique include (1) the main traumatic event occurred during a flagpole exercise, where the patient's trunk was suspended horizontally while a vertical pole was grasped with both hands, (2) headaches were associated with the periscapular injury and they improved after scapulothoracic bursectomy and rhomboid tendon repair, (3) surgical correction was done during the same operation with an open anterior capsular-labral reconstruction, open scapulothoracic bursectomy without bone resection, and rhomboid tendon repair, (4) a postoperative complication of tearing of the serratus anterior and rhomboid muscle attachments with recurrent scapulothoracic pain occurred from patient noncompliance, and (5) the postoperative complication was surgically corrected and ultimately resulted in an excellent outcome at the one-year final follow-up.