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The Journal of Bone and Joint Surgery 80:229-38 (1998)
© 1998 The Journal of Bone and Joint Surgery, Inc.

Contracture of the Deltoid Muscle. Results of Distal Release*{dagger}

JIH-YANG KO, M.D.{ddagger}, KAI-NAN AN, PH.D.§ and RYUJI YAMAMOTO, M.D., PH.D.#, KAOHSIUNG, TAIWAN

Investigation performed at Chang-Gung Memorial Hospital, Kaohsiung


   Abstract
Top
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
We prospectively studied the results of distal release, performed between February 1989 and December 1994 for the treatment of a contracture of the deltoid muscle, in forty patients (forty-nine shoulders). Forty-seven contractures (in thirty-eight patients) developed after multiple intramuscular injections of various medications. The two remaining contractures (in two patients) were congenital. The average age at the onset of the symptoms was thirty-two years (range, birth to fifty-eight years). The primary symptoms included pain around the neck and the shoulder girdle, dimpling of the skin, a palpable fibrous band, winging of the scapula, difficulty in combing the hair or reaching the contralateral side of the body for grooming, and inability to bring the arm adjacent to the body. The average age at the time of the operation was thirty-nine years (range, fifteen to sixty-three years). The average duration of follow-up was three years and eleven months (range, two years to six years and six months). After the distal release of the contracture, but on the same day, the patients started a physical-therapy program. Postoperatively, the pain, dimpling of the skin, palpable fibrous band, and winging of the scapula resolved in forty-eight shoulders (thirty-nine patients). Six patients (six shoulders) no longer had difficulty in combing the hair or adducting the shoulder. There were no infections or neuromuscular complications. Forty-seven (96 per cent) of the forty-nine shoulders (thirty-eight of the forty patients) had a good clinical result, and two shoulders (two patients) had a poor result. Anterosuperior subluxation of the humeral head, noted on preoperative radiographs of twenty-three shoulders (eighteen patients), was not present postoperatively. Drooping of the acromion, seen in six patients (six shoulders) in whom the contracture had developed before they were sixteen years old, improved postoperatively in five shoulders (five patients). Rotation of the scapula, seen in five shoulders (five patients), resolved after release of the contracture in all five. There were no clinical or radiographic signs of osteoarthrosis due to long-term anterior translation of the shoulder joint in the four patients (six shoulders) who had had the contracture for at least twenty years (average, twenty-three years; maximum, twenty-seven years).


   Introduction
Top
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Contracture of the deltoid muscle may develop secondary to congenital fibrosis, intramuscular injection, or trauma, leading to fibrosis of the muscle2,3,5,10,15,27. In Oriental countries, it was common practice to give a series of intramuscular injections to patients who had fever, pain, or infection5,6,21,24. The contracture that developed after repeated intramuscular injections became a social problem and resulted in litigation in some districts21. The contracture has been identified intraoperatively as a fibrous band in the deltoid muscle, and its structure has been confirmed histopathologically1,2. Long-standing contracture of the deltoid muscle produces dimpling of the skin, a palpable fibrous band, dull pain around the neck and the shoulder girdle, and headache. Cosmetic problems include abduction contracture of the shoulder and winging of the scapula5,6,21,25 (Figs. 1-A and 1-B). Limitation of horizontal adduction, leading to difficulty in combing of the hair and use of the upper extremity for grooming of the contralateral side of the body, was believed to be secondary to contracture of the posterior part of the deltoid muscle21. Subluxation or dislocation of the humeral head, rotation of the scapula, and drooping of the acromion have been noted radiographically2,7,13,22,24,29, especially in patients in whom the contracture developed in childhood.



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  		Figs. 1-A and 1-B: Case 17. Fig. 1-A: Photograph showing an abduction contracture of the left shoulder with winging of the scapula. The abduction-contracture angle was measured at the point of intersection of the vertical body axis (a line parallel to the line connecting the spinous processes) and the abducted arm with the shoulder in the anatomical position (a line parallel to the shaft of the humerus).

 


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  		Fig. 1-B: Photograph showing an extension contracture of the left shoulder, dimpling of the skin (arrowhead), and anterosuperior subluxation of the humeral head. The extension-contracture angle was measured at the point of intersection of the vertical body axis and the extended arm with the shoulder in the anatomical position (a line parallel to the anterior border of the humeral shaft).

 
Contracture of the deltoid muscle is relatively uncommon, and the symptoms, such as chronic discomfort around the shoulder girdle and winging of the scapula, usually are non-specific. Therefore, the diagnosis may be missed, leading to inadequate treatment. The presence of instability of the shoulder or rotator-cuff disease makes accurate diagnosis even more difficult. Minami et al. reported a satisfactory clinical result after release of the deltoid contracture in forty patients (forty-nine shoulders). Chatterjee and Gupta achieved full correction in twenty-nine of thirty-one shoulders (fifteen of seventeen patients); those authors discussed the radiographic changes in the shoulder joint but did not provide adequate follow-up data.

In most instances, proximal resection or excision of the fibrous band was performed to release the contracture5,11,13,21,24; however, loss of roundness of the shoulder, a visible gap between the acromion and the detached deltoid, and inadequate release are some of the shortcomings of that procedure. Advancement of the posterior or anterior deltoid fibers to bridge the gap created by resection has been recommended21,24; however, this is impossible if more than two parts of the deltoid muscle are involved. Manske reported the results of distal release in a patient who had diffuse fibrosis of the entire deltoid muscle.

In the current report, we evaluate the results after distal release of a contracture of the deltoid muscle in forty patients (forty-nine shoulders).


   Materials and Methods
Top
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
A prospective study was undertaken to evaluate the results of distal release, performed between February 1989 and December 1994, in forty-seven patients (fifty-eight shoulders) who had a contracture of the deltoid muscle. Approval was not obtained from the institutional review board as the procedure was not a new one. Seven patients (nine shoulders) were excluded from the study: four patients (five shoulders), because they could not be located, and three patients (four shoulders), because they had been followed for less than two years. The remaining forty patients (forty-nine shoulders) formed the basis of this study. A distal release of the fibrous band of the deltoid muscle was performed in all shoulders by the same one of us (J.-Y. K.) at Chang-Gung Memorial Hospital in Kaohsiung.

In thirty-eight patients (forty-seven shoulders), the contracture had developed after repeated intramuscular injections of either analgesics or antibiotics into the deltoid muscle for the treatment of fever, asthma, infection, or pain. None of these contractures developed after the regular use of insulin or antituberculous medications. The two remaining patients (two shoulders) had a congenital contracture of the deltoid. Neither had a history of birth trauma or other congenital anomalies. In six patients (six shoulders), the contracture developed between the ages of eight and fifteen years.

The average age at the time of the operation was thirty-nine years (range, fifteen to sixty-three years). There were twenty-four female patients and sixteen male patients. The right shoulder was involved in twenty-one patients, and the left shoulder was involved in twenty-eight. The middle and posterior fibers of the deltoid were involved in forty-four shoulders (thirty-five patients); the middle fibers only, in four shoulders (four patients); and the entire deltoid muscle, in one shoulder (one patient) that had a congenital contracture (Table I). Preoperatively, information was obtained about the type and quantity of the medication that had been injected, frequency of injection, history of trauma, age at the onset of symptoms, duration of symptoms, associated contractures, localized skin changes, pain, cosmetic problems, and changes in functional activities.


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  		TABLE I PREOPERATIVE AND POSTOPERATIVE DATA ON THE FORTY PATIENTS (FORTY-NINE SHOULDERS)

 
We measured the abduction-contracture, extension-contracture, and horizontal-adduction angles, as well as the range of motion, with a goniometer (Figs. 1-A and 1-B). The abduction-contracture angle was measured at the point of intersection of the vertical body axis (represented by a line parallel to a line connecting the spinous processes) and the abducted arm with the shoulder in the anatomical position (represented by a line along the shaft of the humerus). The extension-contracture angle was measured at the point of intersection of the lateral vertical line and the line along the anterior aspect of the humeral shaft, with the arm extended and the shoulder in the anatomical position. The horizontal-adduction angle was measured with the patient flexing the shoulder to 90 degrees and then adducting it to the maximum extent possible. The angle was at the point of intersection of a line parallel to the midline of the arm and a line perpendicular to the shoulder. If the arm could be adducted medial to the shoulder joint the angle was recorded as a positive value, whereas if it remained lateral to the joint a negative value was recorded. Muscle strength was tested with the shoulder in flexion, extension, and abduction, with the patient sitting; the ability to comb the hair or to touch the contralateral axilla also was recorded.

Anterior protrusion of the humeral head relative to the glenoid (Fig. 1-B), suggestive of anterior subluxation of the humeral head, could be seen on axial or scapular Y radiographs (Fig. 2-A), as described previously15,22,25,27. Rotation of the scapula was assessed on anteroposterior radiographs of the chest, made with both arms in a downward resting position5,13 (Fig. 3-A). A decrease in the degree of overlapping of the scapula and the thoracic cage, as well as a decrease in the distance between the superior angle of the scapula and the coracoid process, were best seen in patients who had unilateral involvement. Axial radiographs, arthrograms, computerized tomography scans, or magnetic resonance images were made when there was a suggestion of subluxation or dislocation of the humeral head or rotator-cuff disease.



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  		Figs. 2-A and 2-B: Case 4. Fig. 2-A: Preoperative axial radiograph of the right shoulder in 90 degrees of abduction and 30 degrees of extension, showing anterior subluxation of the humeral head in relation to the glenoid cavity (arrows and arrowheads).

 


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  		Figs. 3-A and 3-B: Case 8. Fig. 3-A: Anteroposterior radiograph of the chest, showing drooping of the acromion, diminished overlapping of the scapula and the thoracic cage, and rotation (on the left side) of the superior angle of the scapula to the lateral side of the coracoid process.

 
The indications for operative intervention included 25 degrees of abduction contracture or more with the arm at rest, progressive deformity, chronic discomfort or pain, and concern about appearance. The operation was performed with the patient in the beach-chair position with a towel beneath the back, and the upper extremity was draped so that it was freely accessible. A six-to-eight-centimeter longitudinal skin incision was made centered on the insertion of the deltoid, with care taken to avoid exposure of the axillary nerve. The fibrous band was isolated, released with use of electrical cauterization, and then allowed to retract proximally. Normal muscle fibers were preserved to avoid decreasing strength of abduction, flexion, and extension of the shoulder. To confirm that the release was adequate, the elbow was pushed across the midline of the body and against the chest wall. Meticulous hemostasis was obtained, and the skin was closed with non-absorbable sutures. The shoulder then was immobilized in a triangular bandage. Physical therapy was started on the same day. The patient was discharged on the next day, after being instructed with regard to a home exercise program.

Postoperatively, we documented the degree of pain relief; correction of dimpling of the skin and scapular winging; range of motion; abduction-contracture, extension-contracture, and horizontal-adduction angles; degree of functional use of the upper extremity for grooming; results of manual muscle-testing; and complications. One of us (J.-Y. K.) and another physician evaluated the patients independently at one week, two weeks, six weeks, three months, and every six months thereafter. An anteroposterior radiograph and a scapular Y radiograph of the shoulder, as well as an anteroposterior radiograph of the chest that included both shoulder joints, were made one week and six weeks after the operation and every six months thereafter if there were any changes in the shoulder joint.

The clinical result was graded as good if the total residual angle of contracture was 5 degrees or less (that is, if both the abduction-contracture and the extension-contracture angles were 5 degreees or less and the horizontal-adduction angle was 40 degrees or more), as fair if the total residual angle was more than 5 degrees, and as poor if the total residual angle was 15 degrees or more or if complications had led to decreased muscle power or functional activity.

The measurements were based on a consensus between the two observers. There were no major differences between the measurements obtained by the two observers. This is important because the landmarks and lines used to measure the various angles were determined on the basis of visual rather than radiographic parameters.


   Results
Top
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
The average duration of follow-up was three years and eleven months (range, two years to six years and six months). Pain around the neck and shoulder, dimpling of the skin, the palpable fibrous band, and winging of the scapula resolved completely in thirty-nine patients (forty-eight shoulders; 98 per cent) and only partially in one patient (one shoulder). Overall, forty-seven (96 per cent) of the forty-nine shoulders (thirty-eight of the forty patients) had a good clinical result, and two shoulders (two patients) had a poor result (Table I). Four patients (six shoulders), who had had the contracture for at least twenty years (average, twenty-three years; maximum, twenty-seven years), had no clinical or radiographic signs of osteoarthrosis due to long-term anterior translation of the shoulder joint.

The preoperative abduction contracture (average, 29 degrees; range, 20 to 45 degrees) resolved completely in forty-two shoulders (86 per cent [thirty-four patients]). Of the remaining seven shoulders, six (five patients) had a residual abduction contracture of 2 to 5 degrees and one had a 15-degree abduction-contracture angle. The average postoperative abduction-contracture angle was 1 degree (range, 0 to 15 degrees). The preoperative extension contracture (average, 13 degrees; range, 0 to 35 degrees) resolved completely in all forty-nine shoulders. The preoperative horizontal-adduction contracture (average, 2 degrees; range, -20 to 30 degrees) was corrected, permitting at least 40 degrees of abduction, in forty-five shoulders (92 per cent [thirty-seven patients]). The remaining four shoulders (four patients) had a postoperative horizontal-adduction angle of 30, 15, 35, and 35 degrees. Overall, the average postoperative horizontal-adduction angle was 44 degrees (range, 15 to 55 degrees). Six patients (six shoulders) who had had difficulty in combing the hair and grooming the contralateral side of the body regained those functions.

Anterosuperior subluxation of the humeral head was noted on the preoperative radiographs of twenty-three shoulders (eighteen patients); it was not seen in any of these shoulders after the index operation (Fig. 2-B). Two other patients had recurrent anterior dislocation of the shoulder preoperatively. One of these patients (Case 2) had no evidence of instability of the shoulder two years and seven months after the index procedure. The other patient (Case 3) had an inferior capsular shift procedure three months after the release because of persistent dislocations due to multidirectional instability of the shoulder. The intraoperative findings at the time of this subsequent procedure included mild fibrillation of the glenoid labrum, excessive retroversion of the humeral head, and marked laxity of the anteroinferior aspect of the capsule. Before the release of the deltoid contracture, the patient had had three dislocations in one month. Two years and ten months after the capsular shift procedure, she had had no additional dislocations.



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  		Fig. 2-B: Postoperative axial radiograph of the right shoulder in 90 degrees of abduction and 30 degrees of flexion, showing a return of the normal relationship between the humeral head and the glenoid cavity.

 
Of the eight patients (eight shoulders) who had had the deltoid contracture before they were sixteen years old, including the two who had a congenital contracture, five (Cases 1, 4, 6, 7, and 8) had evidence of rotation of the scapula on the preoperative radiographs; this finding was not noted after release of the contracture (Figs. 3-A and 3-B). Drooping of the acromion was noted preoperatively in six patients (Cases 1 through 4, 6, and 8) who had had the contracture before the age of sixteen years, and the drooping decreased in five of them after the index procedure. There was persistent residual drooping of the acromion in the remaining patient.



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  		Fig. 3-B Anteroposterior radiograph of the chest, made eight months postoperatively, showing correction of both the drooping of the acromion and the rotation of the scapula.

 
Three patients (Cases 23, 26, and 32) had signs and symptoms of impingement and a tear of the rotator cuff for two, four and one-half, and three years, respectively. Open anterior acromioplasty and repair of the rotator cuff was performed at one year, twenty months, and fourteen months after release of the deltoid contracture. The attrition of the rotator cuff was an incidental finding.

Preoperatively, manual muscle strength, tested with the shoulder in flexion, extension, and abduction, was normal in all patients. Three months after the procedure, there was no decrease in manual muscle strength.

Two patients (three shoulders) had formation of a keloid, but only one requested additional treatment. Three patients (three shoulders) had calcification at the site of insertion of the deltoid muscle, but they were asymptomatic. There were no wound infections or neuromuscular complications.


   Discussion
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
Abduction contracture of the shoulder due to fibrosis of the deltoid muscle has become an increasingly known entity since it was first described26. The literature consists primarily of case reports1,2,7,8,10,13,15,22,29. Reports of congenital contracture2,8,21,22 have contained no mention of any preceding trauma. Contracture of more than two groups of fibers of the deltoid muscle may lead to drooping of the acromion and migration of the humeral head. Long-standing contracture produces dimpling of the skin, a palpable fibrous band, dull pain around the neck and the shoulder girdle, and headache. Cosmetic problems include abduction contracture of the shoulder and winging of the scapula especially on attempted adduction of the joint3,6,21,25. The only functional disturbance that has been reported is limitation of horizontal adduction that makes it difficult to groom the contralateral side of the body with use of the involved extremity21. Patients who have a history of recurrent dislocation of the shoulder have felt insecure when the shoulder was placed in abduction and external rotation. Operative intervention has been reported to alleviate the chronic discomfort, abduction contracture, and winging of the scapula21,24. However, proximal release of the contracture of the deltoid muscle often has resulted in roundness of the shoulder, a visible gap between the acromion and the detached deltoid, and an inadequate release5,21,24.

The deltoid muscle has three sites of origin (the clavicle, acromion, and scapular spine) and one site of insertion (the deltoid tubercle of the humerus). The main action of the deltoid muscle is abduction of the arm; however, the anterior fibers assist in flexion and internal rotation, and the posterior fibers assist in extension and external rotation. The anterior and posterior fibers of the deltoid muscle converge directly into the tendon, whereas the middle section, which is multipennate, has four intramuscular septa that extend distally from the acromion to interdigitate with three ascending septae from the deltoid tuberosity9. The middle fibers normally contain more connective tissue than the other components of the deltoid muscle28 and usually are the site where fibrous contractures develop2,13, although the posterior fibers often are involved5,6,8,21.

The position of the humeral head is altered depending on the part of the deltoid muscle that is contracted. The shoulder is abducted when the middle fibers of the deltoid are pulled, flexed and abducted when the anterior fibers are pulled, and extended and abducted when the posterior fibers are pulled. Pulling of the middle and posterior fibers causes abduction and extension of the arm, and the humeral head migrates anteriorly and superiorly and rotates externally. Minami et al. noted that the extension-contracture angle was proportional to the degree of contracture of the posterior fibers of the deltoid; the abduction-contracture angle, to contracture of the entire deltoid, especially the middle fibers; and the horizontal-adduction angle, to contracture of the middle and posterior fibers.

Abduction contracture of the shoulder and winging of the scapula due to a deltoid contracture must be differentiated from abduction contracture of the shoulder due to other causes. Brachial plexus palsy also results in an abduction contracture and winging of the scapula; however, this usually involves the infraspinatus and teres minor muscles, and dyskinesia (abnormal involuntary movement) is a prominent feature. Brachial plexus palsy does not result in dimpling of the skin or a palpable fibrous band. Paralysis of the long thoracic nerve results in loss of function of the serratus anterior muscle; this permits unopposed action of the trapezius, which tends to rotate the inferior angle of the scapula outward and forward when the arm is elevated, producing winging of the scapula. Osteochondroma of the scapula, when located on the anterior surface, causes apparent winging of the scapula that resolves after excision. Deltoid contracture often causes aching in the shoulder and can be misdiagnosed as cervical spondylosis or frozen shoulder6.

Intramuscular injections can result in local ischemic necrosis and chemical myositis, which can lead to fibrosis of the muscle. Repeated needle punctures and local trauma to the muscle can cause hemorrhage, necrosis, phagocytosis of muscle fibers, accumulation of mononuclear cells, and cell infiltrates even without the injection of a substance12,16. The contracture usually develops after repeated injections of medication into the deltoid muscle. Furthermore, the chemical composition of some medications or the non-physiological pH of the carrier medium can produce various degrees of histotoxic effects and can stimulate the formation of fibrous tissue. This property and the rapid injection of a large bolus of drugs can lead to muscle fibrosis. Such drugs have included pentazocine, pethidine, dimenhydrinate, vitamin preparations, antibiotics, and antipyretics3,7,10,20. (Most of our patients could not remember the name of the drug that had been injected, but they were able to identify the reason for the injection.) Electromyography has shown no electrical activity in the involved part of the muscle, while the findings on nerve-conduction-velocity studies have been normal5,10,15,16. Intramuscular injections usually are given in the middle or posterior portion of the deltoid to avoid injury to the cephalic vein, lending plausibility to the hypothesis that the contracture occurs in these locations2,6,13,28,29. If the contracture involved the anterior fibers of the deltoid muscle, extension and external rotation would be restricted. The restriction of passive adduction of the glenohumeral joint and the weight of the upper extremity create the appearance of a winged scapula1,25.

There have been few reports of anterior dislocation of the shoulder secondary to contracture of the deltoid muscle7,14; reports of anterior subluxation are more common2,13,29. In the current study, anterosuperior subluxation was seen in twenty-three shoulders (eighteen patients) preoperatively, although none of the patients reported functional disability or symptoms of instability. It is possible, however, that prolonged anterior subluxation will stretch the anterior capsuloligamentous complex and induce or aggravate recurrent anterior dislocation, leading to functional instability (Cases 2 and 3). If this occurs in a patient who has multidirectional instability of the shoulder, a capsular shift procedure is recommended after release of the contracture.

Drooping or depression of the acromion, mentioned by Bhattacharyya and by Hill et al., is believed to be secondary to a long-standing contracture of the deltoid muscle that leads to overgrowth of the proximal humeral epiphysis, resulting in abduction and partial anterior subluxation of the shoulder. Initially, this is compensated for by upward displacement and rotation of the scapula until upward and outward rotation is no longer possible, at which time the abduction deformity becomes obvious2. If the contracture develops in a child who has marked hypermobility of multiple joints, the scapula may not rotate outward and the glenohumeral joint will dislocate. It is difficult to quantify the degree of rotation of the scapula and drooping of the acromion; however, these changes resolve after release of the contracture.

In all three of our patients (three shoulders) who had symptoms suggestive of an impingement syndrome and a tear of the rotator cuff, the contracture had developed after the age of sixteen years. Browne et al. found that, when the humerus is anterior to the plane of the scapula, the tuberosity is in the region of the coracoacromial ligament, which allows further excursion and greater elevation. External rotation of the humerus moves the greater tuberosity from beneath the coracoacromial arch and relaxes the capsular ligamentous constraints, permitting maximum elevation of the arm. Neither our unpublished cadaver study, nor the study of Browne et al., demonstrated any relationship between the abnormal position of the shoulder girdle and symptoms of impingement syndrome.

Oh et al. suggested that, since the fibrosis involves only a portion of the muscle, the deformity can be corrected by simple release of the fibrous band, and other investigators21,24 have agreed with this recommendation. Most authors have performed proximal release or excision of the contracted bands2,5,13,16,21; however, as mentioned, this method has been associated with inadequate release, loss of roundness of the shoulder, and a gap between the acromion and the deltoid. Minami et al. suggested transfer of a portion of the posterior fibers of the deltoid anteriorly or laterally to correct some of these complications. Neviaser and Neviaser believed that an intact deltoid muscle is essential in order to obtain a good functional result after revision procedures for tears of the rotator cuff. Manske apparently was the first to report distal release in a patient who had diffuse fibrosis of the entire deltoid muscle. Resection of the fibrotic component, as recommended by Bhattacharyya, Goodfellow and Nade, and Sato et al., is impossible without removal of the entire muscle. Recession of the insertion of the deltoid to a more proximal attachment releases the contracture and increases glenohumeral motion. Chen et al. also reported encouraging results after distal release. Tachdjian suggested recession of the deltoid muscle at its insertion for the treatment of abduction contracture of the shoulder in patients who had acquired cerebral palsy. We began to perform distal release for the fibrous contracture in February 1989 because the procedure was simple and did not require transfer of muscles to cover any gap between the acromion and the proximal fibers of the deltoid. Normal muscle fibers were preserved to avoid decreasing the strength of abduction, flexion, and extension of the shoulder. In the current study, forty-seven (96 per cent) of the forty-nine shoulders (thirty-eight of the forty patients) had a good clinical result. The extents of correction of the abduction and extension contractures and of improvement in the horizontal-adduction angle compared favorably with those reported by Minami et al. In that study, twenty-three (47 per cent) of forty-nine shoulders had complete resolution of the abduction contracture, seventeen (35 per cent) of forty-nine shoulders had complete resolution of the extension contracture, and fourteen (41 per cent) of thirty-four shoulders had improvement in the horizontal-adduction angle. The visibility of the scar may be considered an unwanted effect of distal release of the contracture.

Theoretically, fibrosis of the deltoid muscle can lead to decreased muscle strength in flexion, extension, and abduction because of loss of the muscle tissue. However, Markhede et al. found surprisingly good function and strength in the shoulder after removal of the deltoid muscle, probably because of hypertrophy of the remaining muscles (the rotator-cuff muscles and the long head of the biceps) and because the maximum torque exerted in a given motion is not the sum of the maximum torque of each of the synergistic muscles. Prolonged anterosuperior translation of the humeral head may lead to incongruence of the glenohumeral joint and to possible degeneration of the cartilage. Lusardi et al. reported mild-to-severe osteoarthrosis of the glenohumeral joint in sixteen of twenty shoulders that had loss of external rotation of the glenohumeral joint, after a previous anterior capsulorrhaphy for recurrent instability. The four patients (six shoulders) in our study who had had the deltoid contracture for at least twenty years did not have clinical or radiographic evidence of osteoarthrosis.

Several questions remain unanswered and require additional study. These include the effect of future operations on the shoulder joint when proximal release of the deltoid has been performed; the possibility of increased and recurrent instability in a patient who has multidirectional instability of the shoulder, traumatic dislocation, or a massive tear of the rotator cuff; a possible association between drooping of the acromion and attrition of the rotator cuff; and a possible increased prevalence of osteoarthrosis of the shoulder joint.

NOTE: The authors thank Horng-Chang Hsu, M.D., Cheng-Yueh Chen, M.D., and Ya-Shueh Chuang for their assistance in the study.


   Footnotes
 
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

{dagger}Read in part at the Nineteenth Annual Meeting of the Japanese Shoulder Society, October 2, 1992.

{ddagger}Department of Orthopedic Surgery, Chang-Gung Memorial Hospital at Kaohsiung, 123, Ta-Pei Road, Niao-Sung, Kaohsiung 833, Taiwan. Please address requests for reprints to Dr. Ko.

§Biomechanics Laboratory, Department of Orthopedics, 128 Guggenheim Building, Mayo Clinic, Rochester, Minnesota 55905.

#Department of Orthopaedic Surgery, Showa University, Fujigaoka Hospital 1-30, Fujigaoka, Midori Ku Yokohama 227, Japan.


   References
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. Bergeson, P. S.; Singer, S. A.; and Kaplan, A. M.: Intramuscular injections in children. Pediatrics, 70: 944-948, 1982.[Abstract/Free Full Text]
  2. Bhattacharyya, S.: Abduction contracture of the shoulder from contracture of the intermediate part of the deltoid. Report of three cases. J. Bone and Joint Surg., 48-B(1): 127-131, 1966.
  3. Branick, R. L.; Roberts, J. L.; Glynn, J. J.; and Beatie, J. C.: Talwin induced deltoid contractures. In Proceedings of the Western Orthopedic Association. J. Bone and Joint Surg., 58-A: 279, March 1976.[Free Full Text]
  4. Browne, A. O.; Hoffmeyer, P.; Tanaka, S.; An, K. N.; and Morrey, B. F.: Glenohumeral elevation studied in three dimensions. J. Bone and Joint Surg., 72-B(5): 843-845, 1990.
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