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The scapula has long been recognized as a key component in shoulder motion and a crucial part of the kinetic chain connecting the body's core and upper extremity. The pectoralis minor (PM) has garnered increasing attention as we better understand scapular kinematics and its role in shoulder pain and dysfunction. This is particularly important in patients with scapular dyskinesis and especially in overhead throwing athletes. The most of these patients achieve their recovery goals through nonoperative management, stretching, and strengthening protocols; however, some patients do not respond to nonoperative modalities. Several studies have recently shown improvement in shoulder motion and outcome scores after open surgical release of the PM from its scapular attachment. Arthroscopic release of the PM can be accomplished in the lateral decubitus position with standard shoulder arthroscopic portals.
Technique Video
See video under supplementary data.
The pectoralis minor (PM) is increasingly recognized as a key contributor to scapular control, scapulohumeral, and scapulothoracic kinematics and overhead shoulder function. PM tightness has been attributed to many factors including muscular imbalances across the shoulder, chronic shoulder malposition or protraction, thoracic kyphosis, and repetitive overhead activity including throwing athletes, weight lifters, and volleyball players.
Often, these patients have positive subacromial impingement signs. This is believed to be associated with a malpositioned and protracted scapula decreasing the potential acromiohumeral space and limiting forward flexion and internal rotation. Overhead athletes, weight lifters, volleyball players, and other at-risk patients have a higher incidence of scapular dyskinesis and, consequently, a shortened PM.
Scapular dyskinesis has been associated with multiple shoulder disorders including subacromial impingement, rotator cuff disease, labral, and acromioclavicular pathologies.
Nonoperative treatment modalities have focused on mobilizing and stretching the shortened or contracted anterior shoulder musculature including the PM and conjoint tendon. Also, working to strengthen and stabilize scapulothoracic dynamics greatly improves shoulder kinematics.
described 3 stretching mechanisms to increase the length of the PM and mobilize the anterior shoulder. This study and others have shown dynamic changes in the length of the PM tendon influenced by these stretching exercises, which in turn allows for mobility and a greater range of scapular control.
This is exaggerated in patients who compete in overhead throwing sports.
There are no reported cases in the literature on isolated arthroscopic PM releases for PM tightness and scapular dyskinesis unresponsive to conservative treatments. There are, however, numerous publications examining the indications and efficacy of an arthroscopic Latarjet, which includes a PM release during liberation of the coracoid. With improvements in technique and instrumentation, this procedure has become a viable option in the treatment of some shoulder instability. This is a universally recognized learning curve to performing this technically difficult procedure, and it often requires additional medial accessory portals in the beach chair position with absolute understanding of the anatomy of the brachial plexus and the anteromedial shoulder.
Arthroscopic versus open Latarjet in the treatment of recurrent anterior shoulder dislocation with marked glenoid bone loss: A prospective comparative study.
This arthroscopic technique is useful as a way to minimize accessory medial portals, remain in the lateral decubitus position, and adequately visualize the coracoid to safely releasing the PM from its superomedial aspect.
Technique
This technique for arthroscopic PM release was developed to show a safe, reproducible, and effective way to approach and release the PM from its attachment at the superomedial aspect of the coracoid process (Video 1). Indications for this operation include patients with a painful scapular dyskinesis who have failed a concerted effort at nonoperative management with physical therapy and PM stretching techniques.
Setup/Positioning
The patient is positioned in the standard lateral decubitus position (Fig 1), and the operative extremity is prepped and sterilely draped with a wide operative field medially to the sternoclavicular joint. The patient should be prepped and draped medial to the coracoid to ensure access for portal placement, but also in the event there is a need to convert to an open surgery.
Fig 1Surgical positioning and setup for a left shoulder in the lateral decubitus position. The STaR (Arthrex Shoulder Traction and Rotation) lateral suspension arm sleeve is used for assistance in arm positioning.
A standard posterior viewing portal is made 1 cm medial and 3 cm distal to the posterolateral corner of the acromion (Fig 2). On entering the glenohumeral joint, a complete diagnostic arthroscopy is performed. Next, the standard anterior portal is established using needle localization in the rotator interval and an outside-in technique. It is important that the anterior portal is placed so that adequate debridement along the superficial border of the subscapularis and the lateral aspect of the coracoid can be readily performed. The only additional accessory portal needed is the mid coracoid portal (MCP), as shown in Figure 2. This is established with needle localization from just superior and medial to the coracoid process. Again, care is taken to ensure proper trajectory and accessibility to the superomedial coracoid.
Fig 2Left shoulder in the lateral decubitus position with the topical anatomy and proposed portal sites marked. (AP, anterior superior portal; MCP, mid coracoid portal; PP, posterior portal.)
After a complete diagnostic arthroscopy, the rotator interval is opened with either a motorized shaver (Arhtrex, Naples, FL) or a radiofrequency ablation (RFA) device (Smith & Nephew, Andover, MD) (Fig 3). It is important to locate and expose the superior border of the subscapularis and the base of the coracoid. The conjoint tendon, and coracoacromial and coracohumeral ligaments are identified (Fig 4). The coracohumeral ligament is released and the coracoid is meticulously exposed from the lateral flexure inferiorly. The most exposure of the coracoid is performed while viewing from the standard posterior portal and working anteriorly. If visibility is difficult, one could make an accessory anterior superior portal for viewing. In addition, a 70° arthroscope is useful for improved visualization. This allows for a complete 360° view of the subscapularis, the coracoid process, and the subcoracoid region.
Fig 3Left shoulder pictured in the lateral decubitus position and viewing from the posterior portal. Shown are the rotator interval (RI), subscapularis (SS), humeral head (HH), and glenoid (G). Also noted here is the long head of the bicep tendon that has previously been tenotomized. It is important to note that the RI is fully released and the SS should be debrided both superficially and deep to the tendon.
Fig 4(A) A left shoulder in the lateral position, viewing from the posterior portal across anteriorly through the rotator interval. The conjoint tendon attachment to the tip of the coracoid is shown. (B) A left shoulder in the lateral position, viewing from the posterior portal across anteriorly through the rotator interval. Shown here is the well-exposed base of the coracoid, the conjoint tendon, and the coracoclavicular ligaments. (C, coracoid; CC, coracoclavicular; CH, coracohumeral ligament; CT, conjoint tendon.)
Once the subcoracoid space is readily visible and clear of debris, the arthroscopic camera is advanced across the joint anteriorly through the rotator interval (Fig 5). The PM tendon is seen coursing superolaterally and attaching to the superomedial aspect of the coracoid (Fig 6). The conjoint tendon is an excellent reference point for orientation when operating in this region of the shoulder.
Fig 5A left shoulder in the lateral position, viewing from the posterior portal across anteriorly through the rotator interval. View as the camera is advanced across into the rotator interval. (C, coracoid; G, glenoid.)
Fig 6(A) A left shoulder in the lateral position, viewing from the posterior portal across anteriorly through the rotator interval. This is viewed using a 30° arthroscope. The switching stick has been introduced through the mid coracoid portal and is showing the path and trajectory to the pectoralis minor attachment on the coracoid. (B) A left shoulder in the lateral position, viewing from the posterior portal across anteriorly through the rotator interval. This is viewed using a 30° arthroscope. The surgical instrument is shown lifting the pectoralis minor muscle at the musculotendinous junction. (C, coracoid; PM, pectoralis minor.)
Once the surrounding anatomy is well visualized, a needle is introduced through the mid coracoid region (Fig 7) ensuring a safe entry and proper trajectory to release the PM tendon from its insertion. The skin incision is typically 1 cm superior and just medial to the coracoid process (Fig 2). Once the MCP is established, a blunt instrument such as a nerve hook or a switching stick is used to bluntly and gently mechanically dissect the subcoracoid bursa free from the neurovascular structures and better define the superior and inferior border of the PM. It is important to readily identify the musculocutaneous nerve traversing just deep and medial to the border of the PM (Fig 8).
Fig 7A left shoulder in the lateral position, viewing from the posterior portal across anteriorly through the rotator interval. This is viewed using a 30° arthroscope. (C, coracoid; PM, pectoralis minor.)
Fig 8A left shoulder in the lateral position, viewing from the posterior portal across anteriorly through the rotator interval. This is viewed using a 30° arthroscope. After the release of the pectoralis minor tendon, the musculocutaneous nerve (red arrow) is readily visible. (PM, pectoralis minor.)
Once the borders of the PM are exposed an RFA can be introduced into the subcoracoid space. Depending on the surgeon's preference, a cannula can be used through this portal for instrument passage. The tendon insertion is palpated and scored with the RFA device and the tendon released adjacent to the superomedial aspect of the coracoid process. The release is performed with the RFA; however, it is important to direct the probe safely away from the musculocutaneous nerve. Another option for release is an arthroscopic meniscal biter or sharp dissection. On release some recoil of the musculotendinous complex is expected. A grasping instrument or switching stick is then used to confirm complete release of any residual adhesions or attachments to the PM (Fig 9). Care is taken throughout the case to locate and protect the relevant neurovascular structures.
Fig 9(A) A left shoulder in the lateral position, viewing from the posterior portal across anteriorly through the rotator interval. This is viewed using a 30° arthroscope. The grasping tool is introduced through the mid coracoid portal and is used to ensure the complete release and mobility of the tendon. (B) A left shoulder in the lateral position, viewing from the posterior portal the rotator interval. This is viewed using a 30° arthroscope. This again shows a fully released pectoralis minor. The grasping tool is introduced through the mid coracoid portal. Of note the musculotendinous junction will recoil along its axis after release. (C, coracoid; PM, pectoralis minor.)
The arthroscopic PM release is usually an adjunct procedure in patients with a painful static protracted scapula or throwing athletes with recalcitrant dyskinesis. The release of the PM should not alter the standard rehabilitation and return to throw postoperative protocol. Periscapular control and strengthening is vital to any dyskinesis rehabilitation. Of equal importance is attention to core strength, balance, and hip and lower extremity mobility and strength.
Discussion
Treatment for patients with scapular dyskinesis and a tight PM is initially nonoperative, including static and dynamic stretching, and periscapular muscular rehabilitation.
Isolated PM release has been reported as a viable option for recalcitrant PM tightness in the symptomatic patient who is unresponsive to nonoperative treatments.
The PM tendon is released as a part of the Latarjet bone block transfer performed for shoulder instability in the setting of bone loss. This can be performed arthroscopically and these patients show improved outcome scores with no definable deficit related to the PM release.
published a series patients with isolated PM tightness. This study included 46 patients with isolated PM tightness over 3 years. There were 6 patients who did not respond to the standardized nonoperative protocol and underwent open release. They noted significant improvement in patient-reported outcomes (Single Alpha Numeric Evaluation score), clinical outcomes (American Shoulder and Elbow Surgeons score), and pain scores (visual analog scale) with objective changes in scapular station in both groups with no reported complications. There were no differences in patient outcomes between the operative and nonoperative groups. All of these patients were able to return to full activities.
On the basis of these results in open PM release, this arthroscopic technique provides a minimally invasive option to avoid open medial dissection around the coracoid and provide a safe approach to the medial coracoid. In addition, this approach can be performed in the lateral decubitus position and can be performed in conjunction with other shoulder arthroscopic procedures.
Although an arthroscopic surgical release of the PM is a viable option in this patient population, it is not without limitations. The technique does introduce the MCP, which is often unfamiliar, and when placed improperly can risk damage to the musculocutaneous nerve, brachial plexus, and surrounding neurovascular structures. It is important to have sufficient visualization of the coracoid, PM, and surrounding anatomy and use needle localization to minimize this risk. Another key to visualization here is to completely expose the lateral flexure of the coracoid before advancing into the subcoracoid space. This allows for working space and visualization with either the 30° or the 70° arthroscope.
Scapular dyskinesis can be a difficult and debilitating problem that has been associated with shoulder pain and dysfunction. Although most patients with scapular dyskinesis and a shortened or tight PM respond well to nonoperative modalities, there is a defined subset of patients who do not respond to these modalities. This is a reproducible and safe technique to perform an isolated arthroscopic PM release in a patient with PM tightness who has not responded to nonoperative modalities including static and dynamic stretching and scapulothoracic training. The utility of this operation is still evolving, and further studies are needed for long-term follow-up and clinical outcomes of patients treated with arthroscopic release of the PM.
This technique describes an arthroscopic release of the pectoralis minor (PM) tendon. The patient is positioned in the right lateral decubitus position, and the left arm is suspended in balanced traction. The right upper extremity is prepared and draped to allow for medial access to the coracoid process. It is important to sterilely drape the arm medial to the sternoclavicular joint. This allows for ample space for the mid coracoid portal and allows for conversion to an open approach if necessitated. The proposed portals are shown here with the standard posterior portal (PP), the anterosuperior portal (AP), and the mid coracoid portal (MCP). The PP is made 1 cm medial and 3 cm distal to the posterolateral aspect of the acromion. The AP and MCP are established under direct visualization using needle localization and an outside-in technique. A diagnostic shoulder arthroscopy is performed and any intra-articular pathology is addressed. Next, the rotator interval is released in its entirety to gain access to the coracoid process. This is most commonly performed with a 50° ArthroCare radiofrequency ablation wand (Smith & Nephew, Andover, MD) and a motorized shaver (Arhtrex, Naples, FL). The arthroscope is advanced into the rotator interval and the base of the coracoid is exposed. Care is taken to completely debride the base and lateral flexure of the coracoid process. It is important to identify the conjoint tendon, the coracoclavicular ligaments, and the coracohumeral ligament. Once this space is opened and the coracoid anatomy is defined, a needle is introduced through the MCP to ensure a proper and safe trajectory to the insertion of the PM on the anteromedial surface of the coracoid. Next, the MCP is established and a blunt switching stick is under to bluntly define the upper and lower borders of the PM tendon. Care is taken to respect the surrounding neural structures including the musculocutaneous nerve located just deep and medial to the PM. This dissection is performed bluntly with a nerve hook or an arthroscopic switching stick until the PM is fully defined and can be safely released from the superomedial coracoid. Next, a radiofrequency device or an arthroscopic biter can be used to resect the insertion of the PM. The border and proposed resection plane can be palpated and scored with the radiofrequency ablator device before release. This is initiated at the upper border of the insertion and carried distally away from the neural structures. Once the PM is fully released from the coracoid, a blunt instrument such as a nerve hook or a switching stick is again used to ensure a 360° release of the PM from any surrounding adhesions. The PM muscle will recoil medially and the musculocutaneous nerve can easily be shown in the surgical field. A 70° arthroscope can be used at any time to enable visualization. This can be particularly useful during the exposure of the subscapularis and the base of the coracoid. Furthermore, this may allow for easier visualization of the PM musculotendinous junction and its insertion at the superomedial coracoid.
Arthroscopic versus open Latarjet in the treatment of recurrent anterior shoulder dislocation with marked glenoid bone loss: A prospective comparative study.
The authors report the following potential conflicts of interest or sources of funding: J.M.T. is a consultant for Arthrex and Johnson and Johnson. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
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