Snapping Scapula Syndrome

Robert Whittaker, SPTUniversity of North Dakota

Overview First described in 1867 by Boinet1

Mauclair later described 3 subclasses Froissement – physiologic friction sound Frotting – louder grating sound associated with pathologic alterations

(soft tissue problems) Craquement – pathologic loud snapping sound (loud/painful grating

sounds by osseous anomalies) http://youtu.be/CTbQG7Jp3Zw

Snapping Scapula (or washboard syndrome1) – painful crepitus of scapulothoracic (ST) articulation, commonly seen in overhead-throwing athletes (noises amplified by thoracic cavity such as a resonance chamber of stringed instrument)2

Dyskinesias caused by pain & muscle weakness, imbalances, inflexibility

Overview ContinuedDyskinesia can increase anterior tilt, decrease

scapular upward rotation, and increase scapular internal rotation1

Anteriorly tilted scapula compresses medial border against ribs and scapula pivots around its medial border rather than sliding laterally

Practice Pattern 4E: Impaired Joint mobility, Motor Function, Muscle Performance, and ROM Associated With Localized Inflammation6

ICD-9-CM Code: 727.3 Other Bursitis Prognosis: Over the course of 2-4 months pt. will

demonstrate optimal recovery (6-24 visits)

Anatomy Scapula’s Role – maintain stable BOS for humerus and dynamic

positioning of the glenoid during GH elevation.2

Clavicle acts as strut for scapula opposing medially directed forces of axioscapular muscles and allowing scapular rotation and translation along thoracic cage

Muscle tendons and bursa located between thorax and scapula – several bursa around ST joint to facilitate smooth movement have potential for scapular dysfunction/crepitus Supraserratus (subscapularis) bursa – between subscapularis, serratus

anterior, & axilla1

Infraserratus (ST) bursa – between serratus anterior, chest wall, & rhomboids1 (facilitates gliding of serratus on chest wall3)

Adventitial bursa (inconsistent findings)2

Superomedial angle: 1 infraserratus & 1 supraserratus Inferomedial Angle: 1 infraserratus Trapezoid bursa located at base of spine of scapula

Bursa Locations3

Neurovascular Anatomy3 Spinal Accessory N

Goes through levator scapula close to superomedial angle & runs along medial border deep to trapezius muscle

Traverse cervical A Branches anastomose into dorsal scapular A & suprascapular A (superficial

branch flows with accessory N) At risk with portal placement cranial to scapular spine or with inadvertent

dissection during open approach3

Suprascaupar N & A run toward suprascapular notch At risk if superomedial scapular resection or superior arthroscopic portal3

Dorsal scapular A flows with dorsal scapular N 1cm medial to medial border Dorsal scapular N/A provides innervation to rhomboids & deep to them

Long thoracic nerve located on surface of serratus anterior Infrequently at risk3

Neurovascular Image3

Pathology Crepitus caused by irritation of several bursa around the scapula2

Chronic, forceful repetitive actions of shoulder mechanisms can induce micro-tears along periosteum at the medial border of the scapula causing a traction osteophyte at muscular attachment of scapula.2

Osseous lesion (i.e. osteochondroma) in ST space may become pathologic

Muscle atrophy (disuse/nerve injury) leads to diminished soft tissue interposition between thorax and scapula

Anatomical variance can lead to incongruity – superomedial & inferomedial angles can have hook shape, Lushka tuberkle Scoliosis & thoracic kyphosis

Healing fractures of rib/scapula with bony angulation May not always be pathologic, snapping may lead to painful

symptoms over time

Diagnosis2

Complaints of pain with increasing activity Scapular noise/crepitus with motion of scapula (single to

multiple noises or only palpation) Tenderness at superior angle & medial border of scapula

Pain over levator scapula, trapezius, & or rhomboids due to contracture & malfunction1

History of overuse (sports including swimming, pitching, weight training, gymnastics, and football)

Observation of (B) asymmetry in scapula Handedness may result in slight depression Winging commonly noted Moderate to severe forward head and anterior rounded shoulders

Diagnosis2 Assess

Flexibility & soft tissue tightness in surrounding muscles (tight Pec Minor contribute to faulty scapular mechanics)

Muscle length & strength (upper/lower trapezius, rhomboids, serratus anterior, latissimus dorsi, levator scapula, rotator cuff, & deltoid.

Scapulohumeral Rhythm (GH elevation:ST rotation 2:1) Elevation induces posterior tilting and scapular ER Faulty patterns include decreased GH motion with increased scapular motion

during elevation

Pain normally not reproducible with isometrics1

Crepitus easily reproduced with arm movements, pain reproduced generally with shoulder abd1

May be accentuated with compression of superior angle against chest wall Pain & snapping decrease with crossing the arm lifting scapula from ribcage1

Pseudowinging may be present to compensate for pain with motion

Diagnosis1

ImagingAP & tangential view3D CT to visualize congruityFluoroscopy to visualize grating/snapping during

shoulder motionMRI for soft tissue lesion

Selective injections of local anesthetic/steroid for symptomatic bursa – transient relief, inflammation likely present3

Differential Diagnosis2 Cervical spine radicular symptoms (Spurling test for radicular

symptoms) C5-C8 can cause symptoms of scapular pain Quick manual cervical myotome test can help rule out nerve origin pain

GH Joint referred pain Shoulder impingement can alter normal scapulohumeral rhythm,

compensates by elevating or protracting scapula to elevate arm more. Leads to overuse of scapular muscles

Electromyogram & nerve conduction time to determine if scapular winging is neurological injury

Other Noises? Trigger point referrals: multifidi, trapezius, levator scapula, scalenes,

serratus posterior superior, serratus anterior, latissimus dorsi, & rhomboids

Conservative Management2

Pain releiving modalities (diathermy, ultrasound, and iontophoresis to undersurface of medial border) Local injections and NSAIDs (If pain persists, PT must be avoided &

injections considered1) Strengthening of weak muscles

Rhomboids, mid/lower trapezius, serratus anterior, teres minor, infraspinatus, posterior deltoid, & longus colli/capitis (most common lower stabilizers, serratus anterior, mid/lower trapezius) Serratus anterior weakness can cause forward tilting inducing crepitus1

Focus on subscapularis & serratus anterior if atrophied3

Scapular add & shoulder shrug strengthen scapular stabilizers (serratus anterior, rhomboids, levator scapular)1

Abduction & elevation of scapula should be avoid from increased pressure and strain on underlying musculature1

Strengthening inhibited/functionally weakened muscles in both OKC & CKC

Continued conservative2

Endurance training should be emphasized due to primary function of scapula of static posturing of shoulder girdle Muscle fatigue can lead to compensatory motion Many roles of scapula are eccentric Patterns of movement that include pt’s. required activities

CKC advantageous in early stages because of stabilization effects Progression from isometric & isotonic to endurance eccentric

strengthening Scaption, press-up, rowing, push-up+ Advanced: eccentric scapular control (plyometric exercises

such as plyoback, D2 PNF, Swiss ball isometric holds

Exercises

Conservative Management2

Stretching of tight muscles Pectoralis major/minor, levator scapula, upper trapezius,

latissimus dorsi, subscapularis, SCM, rectus capitis, & scalenes Weak muscles cannot be optimally strengthened if antagonists

not stretched Postural correction

Thoracic kyphosis, forward head, rounded shoulders, abducted and anterior tilted scapula, sub occipital extension

Will allow for maximal neuromuscular efficiency and improved biomechanics Reduce kyphosis will improve congruency3

Use of thoracic spine mobilization to promote correction Core strengthening – crossroads for energy from LE<->UE

Conservative Management2

Lower scapular stabilization can be facilitated with contraction of contralateral gluteus maximus via thoracolumbar fascia

Pain & inflammation should be guide throughout progression

3-6 months conservative treatment failure, surgical options may be considered Pts. likely to fail include nerve deficits due to damage, bony

incongruities, and those who can snap their scapulas & do so frequently out of habit

Crepitus related to soft tissue, altered posture, winging, or dyskenisa surgery may not be required1

Operative Management2

Pts. with cervical spine & neurological impairment excludedFailure to have pain relief after preoperative

injection may be contraindicatedOpen surgical resection of superomedial angle of

scapula (most common for bone incongruity)Supraspinatus, rhomboid, and levator scapula are

dissected free & superomedial angle resected with oscillating saw & smoothed with rongeurs.

Sling & PROM begins immediately, AROM added at 8 weeks, resistance at 12 weeks

Operative Management2 Bursectomy rather than superomedial angle resection as bone

histologically and grossly normal even despite good results Open procedure

Inferior angle (infraserratus1) Oblique excision distal to inferior angle. Trapezius & latissimus dorsi split in line

with their fibers exposing bursa Bursa sharply excised & any osteophytes removed PT at week 1, gentle throwing in athletes at week 6

Superomedial Bursa2 Vertical incision made medial to vertebral border, trapezius dissected free

(accessory nerve protect1), subperiosteal dissection to free levator scapula & rhomboid and preserve tendinous attachments (dorsal scapular 2cm from medial border protect1)

Bursa resected & bony abnormalities removed, muscles reapproximated with bone drill holes and wound closed in layers with absorbable sutures

Sling for comfort, PROM & pendulum exercises immediately, AROM at week 3, strengthening at week 6, gentle throwing at week 12

Superomedial Open Resection3

Immobilized up to 4 weeks in sling

Pendulum & PROM exercises immediately

AROM ~8 weeks Strengthening ~12

weeks to periscapular muscles

Operative - Arthroscopic2

Low invasiveness, decrease morbidity & preservation of muscle attachments, early postop rehab, shorter hospital stay, & higher compliance1

Painful trapezoid bursa may be missed with arthroscopyAccess & visualization of superior angle of scapula with

standard portals (inferior to scapular spine 3-4 fingerbreadths from medial scapular border to avoid dorsal scapular nerve & artery, accessory nerve, & neurovascular structures at superomedial angle of scapula) After portal positioning, arm brought into chicken wing

position to proceed with arthroscopy

Operative – Arthroscopic1

Pt. prone/lateral position with arm IR “chicken wing”2 medial portals to view at level of scapular spine, second

is working portal located inferior to spine Upper portal 3cm medial to spine of scapula through skin to

pass trapezius, plane between rhomboid major & minor, serratus anterior (caution to avoid pneumothorax or perforate serratus anterior)

Inferior portal between scapular spine & inferomedial scapular angle (instruments point away from coracoid process to reduce suprascapular N injury when working in subscapularis space)

3rd superior portal useful when ST bursectomy associated with resection of superomedial angel of scapula

Operative – Arthroscopic1 3rd Portal – Using superomedial angle of scapula & lateral border of acromion as

landmarks, the position is located between the middle & medial thirds of the line joining these 2 points (anatomical sites of entry must be respected to avoid damage to neurovascular structures & trocar must be passed through as close to ventral surface of scapula as possible to avoid penetration of the thoracic cavity Inside-out method starting with arthroscope in viewing portal that is directed

superiorly from ST space just laterally to the point marked with a needle and exit in the previously marked region corresponding to superior portal

Arthroscope introduced in viewing portal using fluid pressure of 50-60mmHg to ST space

Inferior working portal or from superior 3rd portal instruments are introduced to carry out the procedure (bleeding controlled with radiofrequency device)

Fibrous tissues removed with shawer to find subscapularis (supraserratus) bursa

Supraserratus & infraserrtaus bursa & any fibrous adhesions around removed to expose superomedial angle – resection of superomedial angle if there is a prominence Careful to avoid suprascapular N damage by directing shawer from superior

portal to skin target equidistance from spine to inferior angle.

Arthroscopic Portals1

Operative – Arthroscopic1

RehabPassive mobilization 1st post op dayFull AROM within 1-2 weeksStrengthening should be allowed after 30 daysPt. return to sport 3rd postop month

Other3

Sling for comfort and discontinued within 1 weekPendulum & PROM exercises immediatelyAROM & Strengthening Based on tolerance

Conclusion2

Good to excellent resultsMost return to work/sport within 3-4 months

regardless of operationImportant to address proper thoracic posture,

scapular control, and strength before return to activity

Questions?

References1. Merolla G, Cerciello S, Paladini P, Porcellini G. Snapping scapula syndrome:

Current concepts review in conservative and surgical treatment. Muscles Ligaments Tendons J. 2013;3(2):80-90. doi: 10.11138/mltj/2013.3.2.080; 10.11138/mltj/2013.3.2.080.

2. Manske RC, Reiman MP, Stovak ML. Nonoperative and operative management of snapping scapula. Am J Sports Med. 2004;32(6):1554-1565. doi: 10.1177/0363546504268790.

3. Gaskill T, Millett PJ. Snapping scapula syndrome: Diagnosis and management. J Am Acad Orthop Surg. 2013;21(4):214-224. doi: 10.5435/JAAOS-21-04-214; 10.5435/JAAOS-21-04-214.

4. Goodman CC, Fuller KS. Pathology: Implications for the physical therapist. SAUNDERS W B Company; 2009.

5. Kisner C, Colby LA. Therapeutic exercise: Foundations and techniques. F a Davis Company; 2007.

6. Guide to physical therapy practice. 2nd ed. APTA; 2003.