Snapping scapula syndrome: current concepts review in conservative and surgical treatment

Diagnosis and Treatment of Snapping Scapula Syndrome: A Scoping Review

CONTEXT

Snapping scapula syndrome (SSS) is commonly misdiagnosed and underreported due to lack of awareness.

OBJECTIVE

This scoping review aims to summarize the current evidence related to SSS diagnosis and treatment to aid clinicians in managing the condition more effectively.

DATA SOURCES

PubMed, Medline, and Embase databases were searched for studies related to the etiology, diagnosis, or treatment of SSS (database inception to March 2020).

STUDY SELECTION

Databases were searched for available studies related to the etiology, diagnosis, or treatment of SSS.

STUDY DESIGN

A scoping review study design was selected to explore the breadth of knowledge in the literature regarding SSS diagnosis and treatment.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

Primary outcomes abstraction included accuracy of diagnostic tests, functional outcomes, and pain relief associated with various nonoperative and operative treatment options for SSS.

RESULTS

A total of 1442 references were screened and 40 met the inclusion criteria. Studies commonly reported SSS as a clinical diagnosis and relied heavily on a focused history and physical examination. The most common signs reported were medial scapular border tenderness, crepitus, and audible snapping. Three-dimensional computed tomography had high interrater reliability of 0.972, with a 100% success rate in identifying symptomatic incongruity of the scapular articular surface. Initial nonoperative treatment was reported as successful in most symptomatic patients, with improved visual analogue scale (VAS) scores (7.7 ± 0.5 pretreatment, to 2.4 ± 0.6). Persistently symptomatic patients underwent surgical intervention most commonly involving bursectomy, superomedial angle resection, or partial scapulectomy. High satisfaction rates of surgery were reported in VAS (6.9 ± 0.7 to 1.9 ± 0.9), American Shoulder and Elbow Surgeons scores (50.3 ± 12.2 to 80.6 ± 14.9), and mean simple shoulder test scores (5.6 ± 1.0 to 10.2 ± 1.1).

CONCLUSION

Focused history and physical examination is the most crucial initial step in the diagnostic process, with supplemental imaging used to assess for structural etiologies when nonoperative management fails. Nonoperative management is as effective as surgical management in pain relief and is advised for 3 to 6 months before operative treatment.

Bilateral scapular osteochondroma in Multiple Hereditary Exostosis patient presented with bilateral shoulder pain treated with arthroscopic and open excision: Case report

Introduction and importance

Multiple etiologies for snapping shoulder syndrome have been described in the existing literature. Scapular osteochondroma is considered as a rare etiology and bilateral scapular osteochondroma have rarely been reported to date. Patient can present with discomfort, pain and crepitation. Multiple surgical methods were described and the patient underwent two different surgical methods with preferable outcome for arthroscopic side.

Case presentation

24 year-old male who is known case of Multiple Hereditary Exostosis (MHE) since childhood presented with bilateral shoulder pain and snapping scapula. Computed tomography demonstrated bilateral ventral scapular osteochondromas. One side treated with open excision and other side with arthroscopic excision.

Clinical discussion

Patient exhibited resolution of symptoms, restoration of function on both sides, but he reported cosmetic preference over arthroscopic side and faster recovery from surgery as well in terms of pain resolution and rehabilitation.

Conclusion

Osteochondroma should by one of differential diagnoses for snapping shoulder syndrome. Despite arthroscopic excision is technically demanding, it carries better outcome compared to open excision.

Tennis overuse injuries in the upper extremity

OBJECTIVE

Tennis is a popular sport with high levels of participation. This article aims to describe how upper extremity overuse injuries occur in relation to tennis biomechanics and to review their imaging characteristics and implications for management. In particular, we will review the imaging patterns of internal impingement, scapular dyskinesis, lateral and medial epicondylitis, ulnar collateral ligament insufficiency, valgus extension overload, capitellar osteochondritis dissecans, extensor carpi ulnaris tendinosis and instability, tenosynovitis, triangular fibrocartilage complex injuries, and carpal stress injuries.

CONCLUSION

Tennis is a complex and physically demanding sport with a wide range of associated injuries. Repetitive overloading commonly leads to injuries of the upper extremity. An understanding of the underlying mechanisms of injury and knowledge of these injury patterns will aid the radiologist in generating the correct diagnosis in both the professional and recreational tennis athlete.

Athletic Injuries of the Thoracic Cage

A variety of sports require exposure to high-impact trauma or characteristic repetitive movements that predispose to injuries around the thorax. Appropriate prognostication and timely management are vital, as untreated or undertreated injuries can lead to pain, disability, loss of playing time, or early termination of sports participation. The authors review common athletic injuries of the thoracic cage, encompassing muscular, osseous, and vascular conditions, with an emphasis on mechanism, imaging features, and management. The authors also review pertinent soft-tissue and bony anatomy, along with relevant sports biomechanics. Generalized muscle trauma and more specific injuries involving the pectoralis major, latissimus dorsi, teres major, pectoralis minor, lateral abdominal wall and intercostals, serratus anterior, and rectus abdominis muscles are discussed. Osseous injuries such as stress fractures, sternoclavicular dislocation, costochondral fractures, and scapular fractures are included. Finally, thoracic conditions such as snapping scapula, thoracic outlet syndrome, and Paget-Schroetter syndrome are also described. Specific MRI protocols are highlighted to address imaging challenges such as the variable anatomic orientation of thoracic structures and artifact from breathing motion. Athletes are susceptible to a wide range of musculoskeletal thoracic trauma. An accurate imaging diagnosis of thoracic cage injury and assessment of injury severity allow development of an adequate treatment plan. This can be facilitated by an understanding of functional anatomy, sports biomechanics, and the unique injuries for which athletes are at risk. ^©RSNA, 2021.

Snapping scapula syndrome: pictorial essay

Snapping scapula syndrome manifests as an audible or palpable crackling during the sliding movements of the scapula over the rib cage, often perceived during physical or professional activities. It can be caused by morphological alteration of the scapula and rib cage, by an imbalance in periscapular musculature forces (dyskinesia), or by neoplasia (bone tumors or soft tissue tumors). In this pictorial essay, we review the main causes of snapping scapula syndrome, exemplified by a collection of didactic cases.

Scapulothoracic pathology: review of anatomy, pathophysiology, imaging findings, and an approach to management

Symptomatic scapulothoracic disorders, including scapulothoracic crepitus and scapulothoracic bursitis are uncommon disorders involving the scapulothoracic articulation that have the potential to cause significant patient morbidity. Scapulothoracic crepitus is the presence of a grinding or popping sound with movement of the scapula that may or may not be symptomatic, while scapulothoracic bursitis refers to inflammation of bursa within the scapulothoracic articulation. Both entities may occur either concomitantly or independently. Nonetheless, the constellation of symptoms manifested by both entities has been referred to as the snapping scapula syndrome. Various causes of scapulothoracic crepitus include bursitis, variable scapular morphology, post-surgical or post-traumatic changes, osseous and soft tissue masses, scapular dyskinesis, and postural defects. Imaging is an important adjunct to the physical examination for accurate diagnosis and appropriate treatment management. Non-operative management such as physical therapy and local injection can be effective for symptoms secondary to scapular dyskinesis or benign, non-osseous lesions. Surgical treatment is utilized for osseous lesions, or if non-operative management for bursitis has failed. Open, arthroscopic, or combined methods have been performed with good clinical outcomes.

Arthroscopic management of snapping scapula syndrome improves pain and functional outcomes, although a high rate of residual symptoms has been reported

PURPOSE

To investigate the use of arthroscopy in the management of patients with snapping scapula syndrome, including aetiology, surgical decision-making, outcomes, complications, effectiveness of arthroscopy, and quality of evidence of the existing literature.

METHODS

Three databases (PubMed, Ovid [MEDLINE], and EMBASE) were searched independently and in duplicate to systematically screen the literature. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist guided the reporting and data abstraction. Methodological quality of all included papers was assessed using the MINORS criteria. The results are presented in a narrative summary fashion using descriptive statistics including means, proportions, and ranges.

RESULTS

Overall, 18 studies (5 case reports and 13 case series; all level IV evidence) were identified, including 201 patients (203 shoulders). The mean follow-up period was 32.7 months (range 1-154 months). Surgical decision-making for the use of arthroscopy was most commonly based on a failed trial of initial non-operative management in 17 studies (94%). Overall, 21% of cases achieved complete resolution of pre-operative symptoms, including pain, crepitus, and range of motion, while 68% of cases obtained some clinical improvement, but reported some residual symptoms (persistent crepitus [12%] and persistent scapulothoracic pain [4%]). Moreover, poor outcomes were reported 11% of cases and the most common complication was scapular oedema (6%).

CONCLUSION

Arthroscopic management of snapping scapula syndrome yields improvement in pain, crepitus, and range of motion in a majority of patients; however, most patients experience residual symptoms. Further studies are needed to compare the outcomes of shoulder arthroscopy with other available treatment options for snapping scapula syndrome. Shoulder arthroscopy for snapping scapula can improve patients' symptoms; however, patients must be informed about the high likelihood of persistent symptoms post-operatively.

LEVEL OF EVIDENCE

Systematic review of Level IV studies.

The effectiveness of extracorporeal shock wave therapy in snapping scapula

BACKGROUND

Bursitis of the snapping scapula is commonly a misdiagnosed problem. Extracorporeal shockwave therapy (ESWT) has been used successfully in the treatment of many chronic inflammatory conditions. The aim of this study was to assess and compare the effectiveness of ESWT in the treatment of scapulothoracic bursitis with the outcome of corticosteroid injection.

METHODS

Using the randomized controlled trials 43 patients with scapulothoracic bursitis were divided into two groups. Group 1 ( n = 22) received three sessions of ESWT. Group 2 ( n = 21) received a single local injection of 80 mg of methylprednisolone. Visual analogue scale (VAS) scores were recorded at each follow-up, whereas the level of satisfaction was evaluated using the Roles and Maudsley criteria.

RESULTS

In group 1, the average VAS scores after 1, 2, 3, and 6 months were 39, 30, 27, and 16, respectively, whereas, in group 2, the average VAS scores were 46, 44, 35, and 36, respectively. There was no statistical significance between the two groups in the first and second months. However, after 3 and 6 months, group 1 revealed lower average VAS scores compared to that of the second group with p-values (0.012 and 0.001), respectively. Roles and Maudsley criteria showed that first group patients were 46% excellent, 36% good, 14% acceptable, and 4% had poor results. However, second group patients were 24% excellent, 33% good, 19% acceptable, and 24% had poor results.

CONCLUSION

We believe that ESWT is a beneficial and trustable method of treatment and can be strongly recommended in painful cases of scapulothoracic bursitis.

Management of Snapping Scapula Syndrome

Snapping scapula syndrome is a rare condition caused by the disruption of the gliding articulation between the anterior scapula and the posterior chest wall. The etiology of snapping scapula syndrome is multifactorial, and contributing factors include scapular dyskinesis, bursitis from repetitive use or trauma, and periscapular lesions. Although the majority of cases are initially treated with nonoperative modalities, recalcitrant snapping scapula syndrome can warrant surgical management. This report describes a 34-year-old amateur weight lifter with a 1-year history of increasing pain and fullness over his posterior shoulder region. He reported full shoulder motion associated with an audible, palpable, and painful crepitus, exacerbated with overhead movement and wall pushups. Previous periscapular stabilization exercises and corticosteroid injection yielded minimal resolution of his symptoms. Prior to being referred to the authors' clinic, the patient was evaluated at an outside facility and deemed a suboptimal candidate for arthroscopic bursectomy because of the large size and location of this lesion. Magnetic resonance imaging showed a large polylobulated fluid collection causing scapulothoracic distention. There was no evidence of osseous abnormalities originating from the scapular body. Computed tomography-guided placement of methylene blue and contrast dye was used to facilitate localization and, in an effort to minimize recurrence, ensure the complete removal of bursal tissue. During 8 weeks, this patient recovered unremarkably and returned to full-duty activities with resolution of symptoms. The authors present the management of chronic and recalcitrant snapping scapula syndrome, and report the open excision of the largest scapulothoracic bursal lesion described, to their knowledge, in the English literature. [Orthopedics. 2016; 39(4):e783-e786.].