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PURPOSE: Scapular protraction strength can be evaluated using a hand-held dynamometer (HHD). However, it is necessary to measure the reliability of HHD in individuals with shoulder pain and to minimize the limitations related to the evaluator and the low methodological quality cited in previous studies. This study assessed, with methodological enhancement, the intra- and interrater reliability of belt-stabilized HHD in the assessment of scapular protraction strength in individuals with shoulder pain. METHOD: Fifty individuals with unilateral symptoms of subacromial pain syndrome (20 men, aged 40.5 ± 15.3 years) were evaluated in two sessions using the belt-stabilized HHD for maximum isometric strength of scapular protraction with the individual in the sitting and supine positions. Reliability values were obtained using the intraclass correlation coefficient with the standard error of measurement (SEM and %SEM) and the minimal detectable change (MDC). RESULTS: The intra- and interrater HHD reliability were excellent for all measurements ranging from 0.88 to 0.96 (SEM = 2.0-4.0 kg; %SEM 12 to 17; MDC = 6-11 kg). CONCLUSION: Belt-stabilized HHD is reliable for the assessment of scapular protraction strength in individuals with subacromial pain syndrome in both the sitting and supine positions.

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OBJECTIVES: Novel fascial plane blocks may allow early tracheal extubation and discharge from the intensive care unit (ICU). The present study primarily aimed to determine whether fascial plane blocks, in comparison with intravenous analgesia alone, significantly shortened tracheal extubation times in patients undergoing cardiac surgery. The secondary objectives were to compare each block's performance with that of intravenous analgesia alone in terms of the individual tracheal extubation time and length of ICU stay. DESIGN: Retrospective observational study. SETTING: Single-center study. PARTICIPANTS: Patients who underwent cardiac surgery between 2018 and 2019 were identified from a prospective clinical registry. After obtaining ethics approval, the clinical and electronic records of patients undergoing cardiac surgery in 2018 were analyzed. Data of patients receiving fascial plane blocks (erector spinae plane [ESP], pectoral plane I and II [PECs], and serratus anterior plane [SAP] blocks) with intravenous analgesia were compared with those of patients receiving only intravenous analgesia. A propensity score (PS) model was used to control for differences in the baseline characteristics. Adjusted p < 0.05 was considered statistically significant. MEASUREMENTS AND MAIN RESULTS: Of the 589 patients screened, 532 met the inclusion criteria; 404 received a fascial plane block. After PS matching, weighted linear regression revealed that by receiving a block, the predicted extubation time difference was 9.29 hours (b coefficient; 95% CI: -11.98, -6.60; p = 0.022). Similar results were obtained using PS weighting, with a reduction of 7.82 hours (b coefficient; 95% CI: -11.89, -3.75; p < 0.001) in favor of the block. In the fascial-plane-block group, ESP block achieved the best performance. The length of ICU stay decreased by 1.1 days (b coefficient; 95% CI: -1.43, -0.79; p = 0.0001) in the block group. No complications were reported. CONCLUSIONS: Fascial plane block is associated with reduced extubation times and lengths of ICU stay. ESP block achieved the best performance, followed by PECs and SAP blocks. After PS matching, only ESP block reduced the extubation time.

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Using the serratus anterior fascia may be a safe and effective option to recreate the lateral breast profile during subpectoral breast reconstruction, with minimal functional impact on the donor site. However, the literature is scarce when it comes to studies on this fascia flap in implant-based reconstruction. This article aimed to review the use of the serratus anterior fascia in immediate implant-based breast reconstruction, searching the electronic databases PubMed, Embase, Lilacs, and SciELO. The search was carried out by combining the following keywords: 'breast reconstruction' and 'serratus anterior fascia'. In the Pubmed and Embase databases, the search yielded a total of 12 and 15 articles, respectively, of which seven were selected according to the scope of this article. We found no studies on serratus anterior fascia and breast reconstruction in the Lilacs and SciELO databases. All works have results favorable for the use of the serratus anterior fascia flap and agree that this technique can be considered in the algorithm for the coverage of the inferolateral portion during subpectoral breast reconstruction

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OBJECTIVE: To verify the association of the isometric strength of the shoulder external rotators (ER) and serratus anterior (SA) with the performance of functional tests CKCUEST, SMB-T, and USSP-T in overhead athletes. DESIGN: Cross-sectional study. PARTICIPANTS: Eighty overhead athletes with no history of surgery in the upper and lower limbs and trunk in the past year, and no painful symptoms in the upper body during the physical assessment were included. MAIN OUTCOME MEASURES: Preseason assessment included isometric strength of shoulder ER and SA, and performance of the CKCUEST, SMB-T, and USSP-T. Multiple linear regression analysis was performed to identify if the isometric strength of the shoulder ER and SA could explain the performance during the tests after controlling for sex. RESULTS: The isometric strength of SA was associated (p < 0.05) with the SMB-T and USSP-T with 4% of explain. The isometric strength of the SA was not associated (p > 0.05) with the CKCUEST. The isometric strength of the ER was not associated (p > 0.05) with any of the tests. CONCLUSION: The isometric strength of the SA predicted the SMB-T and USSP-T performance. Isometric strength of SA and shoulder ER was not associated with CKCUEST results in athletes overhead.

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SUMMARY: The variations in the serratus anterior (SA) muscle are common. Here, we report a rare variation of the muscle origin with a potentially great clinical implication. We found an aberrant SA variation in an 81-year-old Korean male cadaver during a routine dissection for medical students. Additional slip (AS) of the SA originated from the clavipectoral fascia and the pectoralis minor. It traveled inferiorly and merged to the typical SA part. Precise knowledge about SA variations is clinically valuable; therefore, clinicians should be aware of the possible variation.

RESUMEN: Las variaciones en el músculo serrato anterior (MSA) son comunes. En este trabajo informamos una variación rara del origen muscular con una implicación clínica potencialmente importante. Encontramos una variación aberrante del MSA en un cadáver masculino, coreano de 81 años, durante una disección de rutina para estudiantes de medicina, con un fascículo adicional del MSA originado en la fascia clavipectoral y el músculo pectoral menor. Este fascículo se dirigió inferiormente y se fu- sionó con la parte común de MSA. El conocimiento preciso sobre las variaciones de MSA es útil clínicamente; por lo tanto, los médicos deben ser conscientes de esta posible variación.

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BACKGROUND: The serratus anterior (SA) is capable of a wide range of actions across the scapulothoracic joint. Furthermore, the lack of control, strength, or activation of this important muscle is believed to be associated with several painful conditions involving the shoulder complex. Studies and clinical intuition have therefore identified several exercises that selectively target the activation of the SA. METHODS: This paper reviews the anatomy, innervation, testing, and complex actions of the SA. In addition, this paper describes the classic signs and symptoms of weakness or reduced activation of the SA. Several exercises are described and illustrated that purportedly target the activation of the SA, with the intention of optimizing muscular control and encouraging pain free shoulder motion. CONCLUSIONS: This review provides the theoretical background and literature-based evidence that can help explain the SA's complex pathokinesiology, as well as guide the clinician to further develop exercises that likely challenge the muscle. This paper is written along with a companion paper entitled: Kinesiologic considerations for targeting activation of scapulothoracic muscles: part 2: trapezius. Both papers prepare the reader to expand their pallet of exercises that target and challenge these two dominant muscles, with a goal of improving function of the shoulder for several painful conditions caused by their reduced or altered activation pattern.

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STUDY DESIGN: Case series. BACKGROUND AND PURPOSE: Scapular dyskinesis has been associated with several shoulder injuries. Recent literature has suggested that a greater activation of the scapular muscles can play an important role in reducing subacromial impingement in patients with shoulder pain. Thus, the purpose of this case series was to describe a rehabilitation program that emphasizes scapular dyskinesis correction for those with clinical evidence of subacromial pain syndrome. CASE DESCRIPTIONS: The four amateur athletes in this series showed clinical evidence of subacromial pain syndrome and scapular dyskinesis and each underwent a treatment protocol consisting of three phases. Phase 1 emphasized pain relief, scapular control, and recovery of normal range of motion (ROM), Phase 2 focused on muscular strengthening, and Phase 3 emphasized sensory motor training. OUTCOMES: All subjects demonstrated decreased pain, improved sports performance and function, increased muscular strength for shoulder elevation and external rotation, and increased ROM for internal rotation. Improvement in serratus anterior (SA) activation was also noted. DISCUSSION: The results of this case series suggest that subjects with clinical tests positive for subacromial pain syndrome can show significant improvement with an intervention focused on scapular dyskinesis correction. SA activation can play an important role in this process given that all subjects presented with better recruitment after rehabilitation, as measured by electromyography. LEVELS OF EVIDENCE: Level 4.

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The present study was performed to assess the electromyographic activity of the scapular muscles during push-ups on a stable and unstable surface, in subjects with scapular dyskinesis. Muscle activation (upper trapezius [UT]; lower trapezius [LT]; upper serratus anterior [SA_5th]; lower serratus anterior [SA_7th]) and ratios (UT/LT; UT/SA_5th; UT/ SA_7th) levels were determined by surface EMG in 30 asymptomatic men with scapular dyskinesis, during push-up performed on a stable and unstable surface. Multivariate analysis of variance with repeated measures was used for statistical analyses. The unstable surface caused a decrease in the EMG activity of the serratus anterior and an increase in EMG activity of the trapezius (p=0.001). UT/SA_5th and UT/ SA_7th ratios were higher during unstable push-ups (p=0.001). The results suggest that, in individuals with scapular dyskinesis, there is increased EMG activity of the trapezius and decreased EMG activity of the serratus anterior in response to an unstable surface. These results suggest that the performance of the push up exercise on an unstable surface may be more favorable to produce higher levels of trapezius activation and lower levels of serratus anterior activation. However, if the goal of the exercise program is the strengthening of the SA muscle, it is suggested to perform the push up on a stable surface.

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Las lesiones del nervio torácico producen parálisis del serrato anterior y originan una deformidad característica (escápula alata), que genera debilidad y alteraciones importantes en la movilidad del hombro. En esta revisión, se analizan conceptos sobre anatomía, etiología, presentación clínica y alternativas terapéuticas.

The long thoracic nerve injuries are manifested by a characteristic deformity called scapula alata, causing weakness, and impaired shoulder mobility. In this review current concepts of the anatomy, etiology, clinical presentation and therapeutic management are analyzed.

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Las lesiones del nervio torácico producen parálisis del serrato anterior y originan una deformidad característica (escápula alata), que genera debilidad y alteraciones importantes en la movilidad del hombro. En esta revisión, se analizan conceptos sobre anatomía, etiología, presentación clínica y alternativas terapéuticas. (AU)

The long thoracic nerve injuries are manifested by a characteristic deformity called scapula alata, causing weakness, and impaired shoulder mobility. In this review current concepts of the anatomy, etiology, clinical presentation and therapeutic management are analyzed. (AU)

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