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Snapping Scapula

Snapping Scapula

Shoulder blade or scapula is an amazing anatomical structure.  What makes it amazing is it is suspended over the ribs between the spine and the arm by only two ligaments.  There is no real joint between the scapula and the trunk.  It is supported by three layers of muscle (superficial, intermediate, and deep) and bursae.  Bursae are small fluid-filled sacs designed to lessen the friction between muscle, tendons and bones.  The layers of the muscle form a smooth surface for the muscle to move, glide and rotate over.  As there is movement without an actual joint, this connection is considered a pseudo joint.

Scapula gives the shoulder a stable base from which it can move.  Scapula also slides, glides and rotates with the shoulder.  This means for every shoulder flexion and abduction, scapula also moves over the thoracic wall, though a lesser degree.  For proper scapulothoracic movement there is a proper length-tension ratio between the shoulder bone and all of the muscles around it.  This is called glenohumeral-to-scapulothoracic ratio.  Any change in this ration can give rise to altered or compromised shoulder movement.  Snapping shoulder is an example of what can happen when any of the layers of muscles is disrupted for any reason.

Snapping scapula is marked by grating, grinding, popping or snapping sensation of the scapula on to the thoracic area of the spine or backside of the ribs when the arm is raised up overhead.  In medical parlance, this sound is often called crepitus.  Snapping scapula is also referred to as “washboard syndrome,” scapulocostal syndrome or scapulothoracic syndrome.  It is a condition attributed to the abnormalities in the bony and soft tissue.  For donkey’s ears, this syndrome was underestimated and related only with specific osseous abnormalities.  The condition triggers of severe pain and is debilitating to the patient suffering from it.  Though snapping scapula syndrome is not very common, when it occurs the soft tissues between the scapula and the chest wall are thickened, irritated, or inflamed. 

What causes snapping scapula?

Snapping scapula occurs due to problems in the soft tissues or bones of the scapula and chest wall.  When the tissues between the scapula and shoulder blade are thickened from inflammation, it can progress to snapping scapula.  Repetitive motion of the shoulder can give rise to inflammation, such as movement of the shoulder during bowling and pitching in cricket and rugby respectively.

Snapping scapula can also happen when the muscles under the scapula have atrophied or shrunk.  It could be because of inactivity or weakness, due to which scapula rides more closely to the ribcage, leading to bumping or rubbing on the rib bones during movement.  Alteration in the contours of the bones of the scapulothoracic joint is another reason for snapping scapula.  When a fractured scapula or rib is not leveled up just right, it can manifest in bumpy ridges that create the typical grind or snap as the scapula gets closer to the chest wall. 

Symptoms of snapping scapula:

As the scapula moves along the chest wall grating, grinding, or snapping may be heard or felt along the edge or undersurface of the scapula.  The joint can pop or thump during movement, though these sensations may not be painful.

Diagnosis of snapping scapula:

Whatever may be the exact cause of a snapping scapula, the outcome is a disturbance in the way the scapula moves along the thoracic wall.  This altered pattern of movement is called scapular dyskinesis or scapular dyskinesia.  Diagnosing the problem is a bit challenging as there is no single test or imaging study that shows clearly what is going on.  In order to arrive at a diagnosis, the doctor may ask many questions about your past medical history.  You should apprise the doctor correctly if you have experienced similar problems in the past, if you have injured your scapula or if any of your activities of daily living require repetitive shoulder movements.

As part of the physical exam, doctor will check the alignment of the scapula.  You may experience pain as you move the shoulder, but it is important for your doctor to know exactly where your problem is coming from.  By palpating the tissues around the scapula, doctor can find out if the tissues are thickened due to inflammation.  Doctor may go for an imaging, such as x-ray, to see between the scapula and ribcage.  An x-ray can shed light on the health of the scapula and rib.  If there is a hint of abnormality in the x-ray, in order to zero in on the diagnosis, doctor may order a CT scan as it will provide a detailed look.

Treatment for snapping scapula:

The conservative treatment methods for treating a snapping scapula are nonsteroidal anti-inflammatories, cortisone shots, trigger point injections, physiotherapy, chiropractic care, and surgery.   The best chance of cure from this painful condition is when the underlying instability in the scapulothoracic area is addressed, which will aid the scapula and ribs to move freely, without abnormal wear and tear.

If the problem is coming from soft tissues, nonsurgical treatments are generally successful.  In that case, the condition can be dealt with nonsteroidal anti-inflammatory drugs (NSAIDs).  Rest and ice packs can help reduce inflammation and ease pain. Working with a physical therapist or an occupational therapist is also a good idea.  If the pain does not go away with first-line treatment, doctor may go for one or two injections of cortisone into the bursa.

Surgery is the last resort and only recommended if conservative measures do not yield any meaningful outcome.  Surgery is generally recommended only if the deformity is the result of a bone abnormality.

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Q & As on Snapping scapula

1.How does it feel for a person with snapping scapula syndrome?

The person with snapping scapula syndrome experiences the following:

  • Pain in the back of the shoulder or the top portion of the shoulder while lifting the arm or shaking the shoulders.
  • Scapula winging, where one edge appears to poke out from the body. 
  • Weakness in the arms of the person.
  • Snapping, grinding, or popping sounds in the scapula region while lifting the arm above. 
  • Inability to perform overhead movement of arms due to pain and associated weakness in the scapula region.

2.What are the main reasons for snapping scapula syndrome?

  • When there is an issue in the soft tissues and bones of the scapula and chest wall, snapping of the scapula happens. This is due to repetitive movements of the shoulder due to which inflammation happens. The tissues between the shoulder blade and the scapula thicken resulting in inflammation.
  • Due to weakness or inactivity, the muscles under the scapula shrink and they rub on the rib bones during any movement. This is another reason for snapping scapula.
  • When the alignment of the bones changes, due to fractures, etc., snapping scapula occurs.
  • If there are any abnormal curves or bumps on the upper edge of the scapula, it may result in a snapping scapula.

3. What is the advice from a physical therapist for recovery from snapping scapula syndrome? 

To speed up recovery, physical therapists advise the following. 

  • During the first 24-48 hours of therapy, you will be advised to rest the area by avoiding movements such as lifting the arm.
  • You should apply ice packs to the scapula region for about 20 minutes every 2-3 hours.
  • The therapist may slowly introduce a passive motion to the arms, neck, shoulder, and scapula and thereby moves to active movements later.
  • Massages and trigger point release are the next steps by the physical; therapist. 
  • Specific exercises that aid in easy recovery are taught by the therapist.

4.What are the general questions asked by the physical therapist when you visit for treatment?

Diagnosis involves thorough investigation and inquiries about your health condition. You may be asked the following questions:

  • When and how did you notice the pain first?
  • Whether you have any pain around your neck area?
  • Do you have any weakness around your shoulder?
  • Is there any popping, grinding, or snapping sound when you are moving your arms?

In addition to this, the physical therapist also performs certain tests to find out the origin of pain. Imaging tests may also be done to confirm the findings.

5. When is a surgery advised and how is it done?

Doctors normally recommend surgery for patients with snapping scapula only if non-surgical treatment methodologies have failed to be effective. If the issue is due to any bone abnormality, surgery may be advised. A small piece of the upper corner of the scapula that is close to the spine is removed. For this, an incision is made just beneath the bone’s top edge. To perform this surgery, the surgeon uses special tools as the tissues that attach to the scapula need to be carefully detached. The upper end is sewn back once the procedure is over. 

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