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Concept: Serratus anterior muscle


Changes in muscle activities are commonly associated with shoulder impingement and theoretically caused by changes in motor program strategies. The purpose of this study was to assess for differences in latencies and deactivation times of scapular muscles between subjects with and without shoulder impingement. Twenty-five healthy subjects and 24 subjects with impingement symptoms were recruited. Glenohumeral kinematic data and myoelectric activities using surface electrodes from upper trapezius (UT), lower trapezius (LT), serratus anterior (SA) and anterior fibers of deltoid were collected as subjects raised and lowered their arm in response to a visual cue. Data were collected during unloaded, loaded and after repetitive arm raising motion conditions. The variables were analyzed using 2 or 3 way mixed model ANOVAs. Subjects with impingement demonstrated significantly earlier contraction of UT while raising in the unloaded condition and an earlier deactivation of SA across all conditions during lowering of the arm. All subjects exhibited an earlier activation and delayed deactivation of LT and SA in conditions with a weight held in hand. The subjects with impingement showed some significant differences to indicate possible differences in motor control strategies. Rehabilitation measures should consider appropriate training measures to improve movement patterns and muscle control.

Concepts: Muscle, Humerus, Shoulder, Deltoid muscle, Clavicle, Glenohumeral joint, Scapula, Serratus anterior muscle


INTRODUCTION: Although palsy of the long thoracic nerve is the classical pathogenesis of winging scapula, it may also be caused by osteochondroma. This rare etiopathology has previously been described in pediatric patients, but it is seldom observed in adults. CASE PRESENTATION: We describe three cases of static scapular winging with pain on movement. Case 1 is a Caucasian woman aged 35 years with a wing-like prominence of the medial margin of her right scapula due to an osteochondroma originating from the ventral omoplate. Histopathological evaluation after surgical resection confirmed the diagnosis. The postoperative course was unremarkable without signs of recurrence on examination at 2 years. Case 2 is a Caucasian woman aged 39 years with painful scapula alata and neuralgic pain projected along the left ribcage caused by an osteochondroma of the left scapula with contact to the 2nd and 3rd rib. Following surgical resection, the neuropathic pain continued, demanding neurolysis of the 3rd and 4th intercostal nerve after 8 months. The patient was free of symptoms 2 years after neurolysis. Case 3 is a Caucasian woman aged 48 years with scapular winging due to a large exostosis of the left ventral scapular surface with a broad cartilaginous cap and a large pseudobursa. Following exclusion of malignancy by an incisional biopsy, exostosis and pseudobursa were resected. The patient had an unremarkable postoperative course without signs of recurrence 1 year postoperatively. Based on these cases, we developed an algorithm for the diagnostic evaluation and therapeutic management of scapula alata due to osteochondroma. CONCLUSIONS: Orthopedic surgeons should be aware of this uncommon condition in the differential diagnosis of winged scapula not only in children, but also in adult patients.

Concepts: Medical terms, Pathology, Physician, Pain, Scapula, Serratus anterior muscle, Winged scapula, Long thoracic nerve


PURPOSE: It is commonly stated that supraspinatus initiates abduction; however, there is no direct evidence to support this claim. Therefore, the aims of the present study were to determine whether supraspinatus initiates shoulder abduction by activating prior to movement and significantly earlier than other shoulder muscles and to determine if load or plane of movement influenced the recruitment timing of supraspinatus. METHODS: Electromyographic recordings were taken from seven shoulder muscles of fourteen volunteers during shoulder abduction in the coronal and scapular planes and a plane 30° anterior to the scapular plane, at 25%, 50% and 75% of maximum load. Initial activation timing of a muscle was determined as the time at which the average activation (over a 25ms moving window) was greater than three standard deviations above baseline measures. RESULTS: All muscles tested were activated prior to movement onset. Subscapularis was activated significantly later than supraspinatus, infraspinatus, deltoid and upper trapezius, while supraspinatus, infraspinatus, upper trapezius, lower trapezius, serratus anterior and deltoid all had similar initial activation times. The effects of load or plane of movement were not significant. CONCLUSIONS: Supraspinatus is recruited prior to movement of the humerus into abduction but not earlier than many other shoulder muscles, including infraspinatus, deltoid and axioscapular muscles. The common statement that supraspinatus initiates abduction is therefore, misleading.

Concepts: Humerus, Shoulder, Rotator cuff, Supraspinatus muscle, Deltoid muscle, Muscles of the upper limb, Scapula, Serratus anterior muscle


: During resistance training protocols, people are often encouraged to target the scapular stabilizing musculature (middle and lower trapezius and serratus anterior) while minimizing shoulder prime mover activation (upper trapezius and large glenohumeral muscles) in their training regime, especially in overhead athletes with scapular dyskinesis. In order to increase the activation levels in the stabilizing muscles without drastically increasing the activation in the prime movers, unstable surfaces are frequently used during closed kinetic chain exercises (CKC). However, the specific influence of Redcord slings (RS) as an unstable surface tool on the shoulder muscle activation levels have rarely been investigated, despite these results may be used for adequate exercise selection. Therefore, a controlled laboratory study was performed on 47 healthy subjects (22 ± 4.31 yr; 176 ± 0.083 cm; 69± 8.57 kg) during four CKC exercises without and with RS: half push-up, knee push-up, knee prone bridging plus, and pull-up. When using RS, serratus anterior muscle activation decreased during the knee push-up and knee prone bridging plus exercise. In addition, a drastic increase in pectoralis major muscle activation was found during the half push-up and knee prone bridging plus exercise. Consequently, the use of RS does not necessarily imply that higher levels of scapular stabilizer muscle activation will be attained. These findings suggest RS might be an appropriate training tool when used within a general strengthening program, but should not be preferred over a stable base of support when training for specific scapular stabilization purposes.

Concepts: Stabilizer, Muscle, Physical exercise, Exercise, Exercise physiology, Pectoralis major muscle, Clavicle, Serratus anterior muscle


The structure and function of the serratus anterior muscle are partitioned into three parts. If the morphological characteristics in each part can be demonstrated in more detail, the cause of dysfunction will probably be identifiable more accurately. The purpose of this study was to demonstrate the details of the structure and innervation in each part of the serratus anterior muscle.

Concepts: Sociology, Demonstration, Social structure, Serratus anterior muscle


Alterations in scapular muscle activity, including excess activation of the upper trapezius (UT) and onset latencies of the lower trapezius (LT) and serratus anterior (SA) muscles, are associated with abnormal scapular motion and shoulder impingement. Limited information exists on the reliability of neuromuscular activity to demonstrate the efficacy of interventions. The purpose of this study was to characterize the reproducibility of scapular muscle activity (mean activity, relative onset timing) over time and establish the minimal detectable change (MDC). Surface electromyography (sEMG) of the UT, LT, SA and anterior deltoid (AD) muscles in 16 adults were captured during an overhead lifting task in two sessions, one-week apart. sEMG data were also normalized to maximum isometric contraction and the relative onset and mean muscle activity during concentric and eccentric phases of the scapular muscles were calculated. Additionally, reliability of the absolute sEMG data during the lifting task and MVIC was evaluated. Both intrasession and intersession reliability of normalized and absolute mean scapular muscle activity, assessed with intraclass correlation coefficients (ICC), ranged from 0.62 to 0.99; MDC values were between 1.3% and 11.7% MVIC and 24 to 135mV absolute sEMG. Reliability of sEMG during MVIC was ICC=0.82-0.99, with the exception of intersession upper trapezius reliability (ICC=0.36). Within session reliability of muscle onset times was ICC=0.88-0.97, but between session reliability was lower with ICC=0.43-0.73; MDC were between 39 and 237ms. Small changes in scapular neuromuscular mean activity (>11.7% MVIC) can be interpreted as meaningful change, while change in muscle onset timing in light of specific processing parameters used in this study is more variable.

Concepts: Muscle, Electromyography, Muscle contraction, Shoulder, Neuromuscular disease, Clavicle, Scapula, Serratus anterior muscle


Study Design Descriptive, laboratory based, cross sectional study. Objectives To describe scapular musculature strength, endurance, and change in thickness in individuals with unilateral lateral epicondylalgia (LE) compared to their uninvolved limb and the corresponding limb of a matched comparison group. Background Reported poor long term outcomes for the non-surgical management of individuals with LE suggests a less than optimal rehabilitation process. Knowledge of scapular muscle function in a working population of individuals with LE may help further refine conservative management of this condition. Methods Twenty eight patients with symptomatic LE and 28 controls matched by age and gender were recruited to participate in the study. Strength of the middle trapezius (MT), lower trapezius (LT), and serratus anterior (SA) was measured with a hand held dynamometer. A scapular isometric muscle endurance task was performed in prone. Changes in muscle thickness of the SA and LT were measured with ultrasound imaging (USI). ANOVA models were used to determine within and between group differences. Results The involved side of the group with LE had significantly lower values for MT strength (P = .031), SA strength (P<.001), LT strength (P = .006), endurance (P = .003), and change in SA thickness (P = .028) when compared to the corresponding limb of the control group. The involved side of the group with LE had significantly lower strength of the LT (P = .023) and SA (P = .016) when compared to their uninvolved limb, however these differences were small and of potentially limited clinical significance. Conclusion When compared to a matched comparison group, there were impairments of scapular musculature strength and endurance in patients with LE, suggesting that the scapular musculature should be assessed and potentially treated in this population. Cause and effect cannot be established as the weakness of the scapular musculature could be a result of LE. J Orthop Sports Phys Ther, Epub 10 Jan 2015. doi:10.2519/jospt.2015.5290.

Concepts: Causality, Cross-sectional study, Muscle, Muscle contraction, Muscular system, Hand strength, Trapezius muscle, Serratus anterior muscle


Scapular winging secondary to serratus anterior muscle palsy is a rare pathology. It is usually due to a lesion in the thoracic part of the long thoracic nerve following violent upper-limb stretching with compression on the nerve by the anterior branch of thoracodorsal artery at the “crow’s foot landmark” where the artery crosses in front of the nerve. Scapular winging causes upper-limb pain, fatigability or impotence. Diagnosis is clinical and management initially conservative. When functional treatment by physiotherapy fails to bring recovery within 6months and electromyography (EMG) shows increased distal latencies, neurolysis may be suggested. Muscle transfer and scapula-thoracic arthrodesis are considered as palliative treatments. We report a single-surgeon experience of nine open neurolyses of the thoracic part of the long thoracic nerve in eight patients. At 6months' follow-up, no patients showed continuing signs of winged scapula. Control EMG showed significant reduction in distal latency; Constant scores showed improvement, and VAS-assessed pain was considerably reduced. Neurolysis would thus seem to be the first-line surgical attitude of choice in case of compression confirmed on EMG. The present results would need to be confirmed in larger studies with longer follow-up, but this is made difficult by the rarity of this pathology. LEVEL OF EVIDENCE: III.

Concepts: Heart, Muscle, Electromyography, Brachial plexus, Scapula, Serratus anterior muscle, Winged scapula, Long thoracic nerve


Imbalance of neuromuscular activity in the scapula stabilizers in subjects with Subacromial Impingement Syndrome (SIS) is described in restricted tasks and specific populations. Our aim was to compare the scapular muscle activity during a voluntary movement task in a general population with and without SIS (n=16, No-SIS=15). Surface electromyography was measured from Serratus anterior (SA) and Trapezius during bilateral arm elevation (no-load, 1kg, 3kg). Mean relative muscle activity was calculated for SA and the upper (UT) and lower part of trapezius (LWT), in addition to activation ratio and time to activity onset. In spite of a tendency to higher activity among SIS 0.10-0.30 between-group differences were not significant neither in ratio of muscle activation 0.80-0.98 nor time to activity onset 0.53-0.98. The hypothesized between-group differences in neuromuscular activity of Trapezius and Serratus was not confirmed. The tendency to a higher relative muscle activity in SIS could be due to a pain-related increase in co-activation or a decrease in maximal activation. The negative findings may display the variation in the specific muscle activation patterns depending on the criteria used to define the population of impingement patients, as well as the methodological procedure being used, and the shoulder movement investigated.

Concepts: Epidemiology, Muscle, Electromyography, Activity, Task, Scapula, Serratus anterior muscle, Levator scapulae muscle


BACKGROUND: Shoulder pain and dysfunction can occur following neck dissection surgery for cancer. These conditions often are due to accessory nerve injury. Such an injury leads to trapezius muscle weakness, which, in turn, alters scapular biomechanics. OBJECTIVE: The aim of this study was to assess which strengthening exercises incur the highest dynamic activity of affected trapezius and accessory scapular muscles in patients with accessory nerve dysfunction compared with their unaffected side. DESIGN: A comparative design was utilized for this study. METHODS: The study was conducted in a physical therapy department. Ten participants who had undergone neck dissection surgery for cancer, with signs of accessory nerve injury, were recruited. Surface electromyographic activity of the upper trapezius, middle trapezius, rhomboid major, and serratus anterior muscles on the affected side was compared dynamically with that of the unaffected side during 7 scapular strengthening exercises. RESULTS: Electromyographic activity of the upper and middle trapezius muscles of the affected side was lower than that of the unaffected side. The neck dissection side affected by surgery demonstrated higher levels of upper and middle trapezius muscle activity during exercises involving overhead movement. The rhomboid and serratus anterior muscles of the affected side demonstrated higher levels of activity compared with the unaffected side. LIMITATIONS: Exercises were repeated 3 times on one occasion. Muscle activation under conditions of increased exercise dosage should be inferred with caution. CONCLUSIONS: Overhead exercises are associated with higher levels of trapezius muscle activity in patients with accessory nerve injury following neck dissection surgery. However, pain and correct scapular form must be carefully monitored in this patient group during exercises. Rhomboid and serratus anterior accessory muscles may have a compensatory role, and this role should be considered during rehabilitation.

Concepts: Muscle, Physical exercise, Neurology, Electromyography, Trapezius muscle, Scapula, Accessory nerve, Serratus anterior muscle