Transcript Snapping Scapula Syndrome - Robert Whittaker

Snapping Scapula
Syndrome
Robert Whittaker, SPT
University 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 overheadthrowing athletes (noises amplified by thoracic cavity such as a
resonance chamber of stringed instrument)2
 Dyskinesias caused by pain & muscle weakness, imbalances,
inflexibility
Overview Continued
 Dyskinesia 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
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Spinal Accessory N
 Goes through levator scapula close to superomedial angle & runs along medial border
deep to trapezius muscle
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Traverse cervical A
 Branches anastomose into dorsal scapular A & suprascapular A (superficial branch flows
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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
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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
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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
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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 ribcage 1
 Pseudowinging may be present to compensate for pain with motion
Diagnosis1
 Imaging
 AP & tangential view
 3D CT to visualize congruity
 Fluoroscopy to visualize grating/snapping during shoulder
motion
 MRI 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)
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C5-C8 can cause symptoms of scapular pain
Quick manual cervical myotome test can help rule out nerve origin pain
 GH Joint referred pain
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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
excluded
 Failure to have pain relief after preoperative injection may
be contraindicated
 Open 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
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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
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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 arthroscopy
 Access & 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
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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
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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
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Arthroscope introduced in viewing portal using fluid pressure of 50-60mmHg to ST space
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Inferior working portal or from superior 3rd portal instruments are introduced to carry out the
procedure (bleeding controlled with radiofrequency device)
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Fibrous tissues removed with shawer to find subscapularis (supraserratus) bursa
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Supraserratus & infraserrtaus bursa & any fibrous adhesions around removed to expose
superomedial angle – resection of superomedial angle if there is a prominence
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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
 Rehab
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Passive mobilization 1st post op day
Full AROM within 1-2 weeks
Strengthening should be allowed after 30 days
Pt. return to sport 3rd postop month
 Other3
 Sling for comfort and discontinued within 1 week
 Pendulum & PROM exercises immediately
 AROM & Strengthening Based on tolerance
Conclusion2
 Good to excellent results
 Most return to work/sport within 3-4 months regardless
of operation
 Important to address proper thoracic posture, scapular
control, and strength before return to activity
Questions?
References
1.
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.