Scapular Muscle Detachment

Fig. 11.1

Illustration of the scapular muscle detachment injury to both the rhomboid major and lower trapezius muscles

Fig. 11.2

(a) Mobilization of the infraspinatus away from the medial border of the scapula prior to drill hole placement. (b) Pairs of drill holes being placed in the medial scapular border and spine of the scapula

Fig. 11.3

(a) Illustration of the reattachment of the rhomboid major. (b) Illustration of the reattachment of the lower trapezius

Fig. 11.4

(a, b) A comparative illustration of the presurgical injury (a) to the postsurgical repair (b)

Postoperatively, the arm is protected in neutral rotation for 4 weeks, but gentle scapular retraction is encouraged immediately. During this period of recovery, common tasks such as mobile device use, driving, and other repetitive arm tasks with either the surgical or nonsurgical arm can create pain and muscle spasm due to “crosstalk” between the contralateral scapular muscles. In addition, the typical deconditioning/atrophy seen with postsurgical immobilization allows for easy arm fatigue, increasing the pain and spasm. Therefore, patients are instructed to not perform these tasks until after the sling has been removed about 3–4 weeks following surgery. At 4 weeks, closed chain activation up to 90° abduction with the hand stabilized is started. By 6–8 weeks, as the repair has healed and early strength is gained, motion over 90° is allowed, and the patient is started on the standard scapular strengthening program. Maximum strength is not regained for about 6–9 months, probably reflecting the chronic muscle disuse and atrophy.

Postsurgical Outcomes

In the original report describing the outcomes of surgical treatment in a large group with long-term follow-up, the entire group did well, achieving significant improvements in pain and function [11]. At discharge from active care, the ASES pain scores improved from 18/50 to 35/50, function scores improved from 20/50 to 28/50, and total ASES scores improved from 38/100 to 62/100 (p < 0.001). These results were maintained at minimum of 2-year follow-up. While the entire group did well, there was variation in the patient-reported outcomes. To look closely at the outcome variation, a subsequent evaluation subclassified the group based on achieving minimal detectable change for the total ASES score (>10 points) [13]. Fifty-eight of 78 patients (74%) did report greater than 10-point change and were considered significantly clinically improved. Twenty of 78 patients (26%) did not achieve at least a 10-point change on the ASES and were considered not significantly improved (Table 11.1).

Table 11.1

American Shoulder and Elbow Surgeons (ASES) scores between responders and nonresponders to scapular muscle reattachment surgery

	Responders (n = 58)	Nonresponders (n = 20)
	Presurgery
ASES pain	16 ± 11	27 ± 12*
ASES function	18 ± 11	24 ± 9
ASES total	34 ± 16	50 ± 12*
	Post-surgery
ASES pain	38 ± 10*	26 ± 12
ASES function	31 ± 11*	21 ± 10
ASES total	69 ± 18*	42 ± 16
Change from presurgery	35 ± 18*	−8 ± 14

*Significantly greater score p < .001

There may be several factors that contributed to this difference in patient-reported outcome in this group whose diagnosis, inclusion criteria, and surgical treatment are so homogenous. Among them are altered functional demands in the postoperative and return to activity phases, differences in implementation and completion of rehabilitation in the widely geographically dispersed group, chronicity of the injury with its effects on muscle strength and activation, and patient expectations and perceptions of the clinical problem and its effects on function.

One major patient-oriented effect that can impact reported outcomes is perception of pain. This factor has been noted following other types of shoulder procedures [14–18]. A pilot study assessed pain perception for a group of 31 postoperative patients with the #Pain Catastrophizing Scale (PCS) [19]. This 13-item self-reported scale estimates the patient’s attitude toward the effect of pain on their function in their daily lives, which has a maximum scope of 65 (lower score = less pain catastrophizing characteristics). Twenty-one patients were classified as non-catastrophizers (PCS scores <30), while ten patients were classified as catastrophizers (PCS scores ≥30) meaning that they were prospectively and constantly aware of pain which they perceived would negatively impact their function. This patient-perceived effect was shown to impact reported outcome in several ways.

Only gold members can continue reading. Log In or Register to continue