Snapping Scapula Syndrome - PowerPoint Presentation

Slide1

Snapping Scapula Syndrome

Robert Whittaker, SPT

University of North DakotaSlide2

Overview

First described in 1867 by Boinet

1

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 syndrome

1

) – 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, inflexibilitySlide3

Overview Continued

Dyskinesia can increase anterior tilt, decrease scapular upward rotation, and increase scapular internal rotation

1

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 Inflammation

6

ICD-9-CM Code: 727.3 Other Bursitis

Prognosis: Over the course of 2-4 months pt. will demonstrate optimal recovery (6-24 visits)Slide4

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, & axilla

1

Infraserratus

(ST) bursa – between

serratus

anterior, chest wall, & rhomboids

1

(facilitates gliding of

serratus

on chest wall

3

)

Adventitial bursa (inconsistent findings)

2

Superomedial

angle: 1

infraserratus

& 1

supraserratus

Inferomedial

Angle: 1

infraserratus

Trapezoid bursa located at base of spine of scapulaSlide5

Bursa Locations3Slide6

Neurovascular Anatomy3

Spinal Accessory N

Goes through levator scapula close to

superomedial

angle & runs along medial border deep to trapezius muscle

Traverse cervical A

B

ranches 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 approach

3Suprascaupar N & A run toward suprascapular notch

At risk if

superomedial

scapular resection or superior arthroscopic

portal

3

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 risk

3Slide7

Neurovascular Image3Slide8

Pathology

Crepitus caused by irritation of several bursa around the

scapula

2

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 scapulaAnatomical 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 timeSlide9

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

& malfunction

1

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 notedModerate to severe forward head and anterior rounded shouldersSlide10

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

isometrics

1

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

abd

1

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 motionSlide11

Diagnosis1

Imaging

AP

& tangential

view

3D

CT

to visualize congruity

F

luoroscopy to

visualize grating/snapping during shoulder motion

MRI for soft tissue lesionSelective injections of local anesthetic/steroid for symptomatic bursa – transient relief, inflammation likely present3Slide12

Differential Diagnosis2

Cervical spine radicular symptoms (

S

purling

test for radicular symptoms)

C

5

-C

8

can cause symptoms of scapular pain

Quick manual cervical myotome test can help rule out nerve origin pain

GH Joint referred painShoulder 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

, & rhomboidsSlide13

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 considered

1

)Strengthening of weak musclesRhomboids, 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 crepitus

1

Focus on

subscapularis

&

serratus

anterior if atrophied

3

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 musculature

1

Strengthening

inhibited/

functionally weakened muscles in

both

OKC &

CKCSlide14

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 holdsSlide15

ExercisesSlide16

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 congruency

3

Use of thoracic spine mobilization to promote correction

Core strengthening

–

crossroads for energy from LE<->UESlide17

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 required1Slide18

Operative Management2

Pts. with cervical spine & neurological impairment excluded

Failure to have pain relief after preoperative injection may be contraindicated

Open

s

urgical

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 weeksSlide19

Operative Management2

Bursectomy

rather than

superomedial

angle

resection as bone histologically and grossly normal even despite good results

Open procedure

Inferior angle (infraserratus

1

)

Oblique excision distal to inferior angle. Trapezius &

latissimus dorsi split in line with their fibers exposing bursaBursa sharply excised & any osteophytes removed

PT at week 1, gentle throwing in athletes at week 6

Superomedial

Bursa

2

Vertical incision made medial to vertebral border, trapezius dissected free (accessory nerve protect

1

),

subperiosteal

dissection to free levator scapula & rhomboid and preserve

tendinous

attachments (dorsal scapular 2cm from medial border protect

1

)

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 12Slide20

Superomedial Open Resection

3

Immobilized up to 4 weeks in sling

Pendulum & PROM exercises immediately

AROM ~8 weeks

Strengthening ~12 weeks to

periscapular

musclesSlide21

Operative - Arthroscopic2

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

1

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 arthroscopySlide22

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)

3

rd

superior portal useful when ST

bursectomy

associated with resection of

superomedial

angel of scapulaSlide23

Operative – Arthroscopic1

3

rd

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

3

rd

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.Slide24

Arthroscopic Portals1Slide25

Operative – Arthroscopic1

Rehab

Passive mobilization 1

st

post op day

Full AROM within 1-2 weeks

Strengthening should be allowed after 30 days

Pt. return to sport 3

rd

postop month

Other3

Sling for comfort and discontinued within 1 weekPendulum & PROM exercises immediatelyAROM & Strengthening Based on toleranceSlide26

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 activitySlide27

Questions?Slide28

References

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.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.

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.

Goodman

CC, Fuller KS.

Pathology: Implications for the physical therapist.

SAUNDERS W B Company; 2009.

Kisner

C, Colby LA.

Therapeutic exercise: Foundations and techniques.

F a Davis Company; 2007

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