disclosures. There's no relevance for the talks that we're going to do. So a snapping scapula can occur in a couple of different spots. And it depends upon the patient's arc of motion where they may experience it. Sometimes throwers may have something that occurs more at the inferior angle of the scapula versus some patients may experience it more superiorly. So we really have to pay attention to scapulothoracic kinematics. Generally speaking there's a 2 to 1 ratio in terms of how the glenohumeral joint and the scapula moves. This is actually a video of a Vietnam vet who got shot and sustained an injury both to his spinal accessory nerve and his long thoracic nerve. So he has this very combined, very problematic pattern of scapular dyskinesia. So it's imperative you examine these patients with the scapula exposed. And there are a couple of different bursts to keep in mind. One is between the serratus and the chest wall and another one may actually be between the subscapularis and the serratus. And beware scapular winging. So here's a patient that actually had bilateral superior medial open resections and she continued to have crepitation on her right side and she was sent to me for evaluation. And in fact what she had was scapular winging on the right that actually changed the angle of her scapula, how it interacted with the chest wall. Also be mindful of glenohumeral joint pathology that can lead to disrupted scapular kinematics and that can be in the form of someone that has intraarticular pathology, suprascapular neuropathy, slap lesions, et cetera. And again this can lead to an aberrant scapular kinematics. So why do we care? Well the scapula is really the foundation of the shoulder and how it moves. And so we need to evaluate for sick scapula syndrome, especially on our overhead athletes. Be mindful of parascapular muscle detachment, i.e. the Kibler procedure. And also look for neuromuscular lesions and again highlight the whole winging aspect because patients may come to you with all sorts of problems including glenohumeral instability and the problem may be a scapula that moves all over the place. So evaluate scapular position. That's critically important. Look at the angles. You look at whether or not they're protracted or retracted. And look at different patterns of winging and sometimes you may see something like this unilateral sprangles and this kid could make a scapular crack all day long just on the right side but not the left. So again it's very important to evaluate these patients and see the skin, see the muscle patterns. So these are patients that had resolved winging but they also initially presented with scapular thoracic crepitation. One is obviously someone that underwent a PEC minor, excuse me, a PEC major transfer. And this was the gentleman I showed earlier who actually we did a scapula thoracic arthrodesis on. And then here is the patient that I also showed earlier and her scapular winging is resolved. And what we did for her was actually perform a long thoracic nerve decompression endoscopically. And we were also able to then sneak under her scapula and perform a debridement. And so just briefly what that technique looks like. So here the patient's in a lateral decubitus position and actually we're creating a space basically just underneath the skin so we can look down on top of the serratus anterior. So it's a three portal technique. I like using inflow-outflow systems. And then you want to visualize the anterior aspect of the serratus. And so as we go further, so this is a different patient. Down at the bottom you can see the extraticular camera. And this was a patient that every time they brought their arm overhead would have winging and crepitation. And what you can see is the long thoracic nerve, which periodically will show up next to the arrow, was tethered by a vascular bundle. So what we did was go in and basically cauterize that vascular bundle and then perform a more distal dissection of the branches as they arborized into the serratus further down. That also allows us to work underneath the scapula. But the more traditional subscapular vasoscopy we do when someone comes in primarily with a snapping scapula, either from some soft tissue pathology or some bony protuberance, and you can see this often with post-traumatic cases. And here we're just doing a diagnostic injection. You can also add cortisone to make it somewhat therapeutic. And I put him in the chicken wing position that I actually use at the time of surgery. And we're heading towards the superior medial angle of the scapula and providing the injection. I will tell you, be very reluctant to become the doctor that sees all the parascapular pain. That is a very painful practice to have. So here's an example of some of the scapular lesions we've treated over the years. This was an osteochondroma. The French have a couple of terms for whether it's soft tissue problems, which is frodemont or bony pathology, which they call croquement. It sounds great, but it's still painful when you see the patients because they've very often been dealing with this for years. So basically, we're going to introduce the arthroscope in the potential space between the scapula and the thorax. And if necessary, you can actually go a little further and get in between the serratus and the subscapularis and even in between the scapular body. But you have to be very careful if you do that because you can easily penetrate the scapular body if you're not careful. Here's a post-traumatic case that interestingly enough, this fracture pattern wasn't the problem. It was as we got further distally laterally because of the angle of the scapular body had changed. We needed to do a resection in this area to alleviate the crepitation. So again, I prefer this lateral chicken wing position rather than a prone position because I think it averts the scapula easier. Again, it allows for a three-portal technique, which I prefer so you get continuous inflow-outflow. And what we're going to see here, I positioned them on a beanbag, and the beanbag actually can serve as an arm holder for you. But it also, and we put them on an axillary roll and we let the patient's thorax slightly tip forward. And so that again basically pulls the scapula away from their chest wall. And it also allows a scapula that is somewhat mobile so you can move it around. And so you can see how we've got this patient positioned. The scapula moves. The arm's relatively stable. And this is how we're going to begin the scope. And then again, typical three-portal technique. And this is just the setup. So anyone that's familiar with placing their patients in a lateral position, you're just on the opposite side of the body when you do this. And some intra-articular video here or intra-thoracic video, I guess, inter-thoracic. So you want to develop the space in between the scapula and the thorax. So here we're looking down. And what we're doing is just cleaning up in this particular patient some very dense soft tissue and adhesions that were between his scapula and his chest wall. And as you start slicing through this junk, you can really start getting some good exposure. And then if someone needs a bony resection, you start heading up to that superior medial border. And in this case, that would be towards the left of the screen. Here's a different patient that had these very dense fibrous bands that were actually crossing from their ribs over into the subscapular tissue. So again, just like you would on any other arthroscopy, we're using a simple biter to resect this tissue. And then for those of you who want to do a superior medial resection, you can turn your eyes up and make it look like the acromion. So here what we're doing is just gently teasing off the soft tissue from the superior medial scapula, taking care not to detach the rhomboids or the periscopular muscles. And then we'll introduce our burr and basically take down bone. And this is a very simple procedure. Typically this takes between 30 and 45 minutes. I think the real hard part is identifying what the source of the problem is and treating them appropriately. So that's it. Thank you very much.

scapular dyskinesia

shoulder-related issues

scapulothoracic kinematics

scapular position

winging