This review explores the causes of scapula winging, with overview of the relevant anatomy, proposed aetiology and treatment. Particular focus is given to lesions of the long thoracic nerve, which is reported to be the most common aetiological factor. INTRODUCTIONScapular winging is painful and incapacitating [1,2]. The composite movements of the scapula in rotation, abduction and tilting are essential for normal shoulder function and, if this anchored gliding of the scapula (against the posterior chest wall) is lost, then shoulder abduction can be limited to 90• C or less and the ability

Digital rectal examination has no significant value in the acute diagnosis of cauda equina syndrome. This study further confirms that there is no discreet clinical protocol applicable with which to confidently confirm or rule out this diagnosis. DRE is traditionally enshrined as an essential facet of clinical assessment in suspected cauda equina syndrome but it cannot be used as a discriminator to ration urgent MRI scanning.

Background Consensus favours conservative treatment for atraumatic shoulder instability, but literature is scarce on the topic. We therefore prospectively assessed the results of structured physiotherapy for these patients. Methods Patient reported outcomes were recorded prior to physiotherapy and on discharge. Notes review identified patients re-referred for the same condition. Results N = 85. Review range was 12–72 months post-treatment. Median Oxford Shoulder Instability Score (OSIS) improved from 21 (range: 2–47) to 39 (11–47). Median Western Ontario Shoulder Instability Index (WOSI) improved from 1117 (range: 306–2028) to 485 (0–1569). Patients with posterior instability demonstrated better results compared with other groups (OSIS change, p = 0.025; WOSI change, p = 0.060). Quicker referral to physiotherapy gave improved outcomes (OSIS change, p = 0.004, rs = −0.4; WOSI change, p = 0.047, rs = 0.24). Twenty-one patients (24.7%) were re-referred, seven of them for repeat physiotherapy and 14 of them for surgery. Previous surgery significantly affected the possibility of a further referral ( p < 0.001), and initial diagnosis was significantly correlated with further surgery ( p = 0.032). Discussion Early referral to physiotherapy may produce better results. Patients with posterior instability responded better to physiotherapy. Previous surgery increased the risk of re-referral. Re-referred patients with posterior instability tended to be managed with further physiotherapy.

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