Clinical management of scapulothoracic bursitis and the snapping scapula

Abstract

Context: Symptomatic scapulothoracic bursitis and crepitus are disorders of the scapulothoracic articulation that are often poorly understood. They can be a source of persistent pain and dysfunction in the active overhead throwing athlete. It is important to distinguish between scapulothoracic bursitis and scapulothoracic crepitus. Scapulothoracic bursitis refers to inflammation of the bursae secondary to trauma or overuse owing to sports activities or work. Scapulothoracic crepitus is defined by a grinding, popping, or thumping sound or sensation secondary to abnormal scapulothoracic motion.

Evidence acquisition: This article presents the causes, diagnosis, and management of these shoulder conditions in a manner that is relevant to clinicians, athletic trainers, and physical therapists, and it reviews relevant studies to determine the consensus on nonoperative treatment, as well as open and arthroscopic surgical treatment.

Results: The causes of scapulothoracic bursitis and crepitus include direct or indirect trauma, overuse syndromes, glenohumeral joint dysfunction, osseous abnormalities, muscle atrophy or fibrosis, and idiopathic causes. Scapulothoracic bursitis and crepitus remain primarily clinical diagnoses; however, imaging studies or local injections may also be helpful. The initial treatment of scapulothoracic bursitis and scapulothoracic crepitus should be nonoperative. Surgical treatment options include partial scapulectomy or resection of the superomedial angle of the scapula, open bursal resection, and arthroscopic bursectomy. Despite the lack of agreement among orthopaedic surgeons concerning which procedure is best for treating symptomatic scapulothoracic bursitis and crepitus, most reports have demonstrated good to excellent outcomes in a significantly high percentage of patients.

Conclusion: Clearly, the best initial approach to these conditions is a nonoperative treatment plan that combines scapular strengthening, postural reeducation, and core strength endurance. The addition of local modalities, nonsteroidal anti- inflammatory drugs, and localized injections may also be helpful. If an appropriate trial of nonoperative management proves unsuccessful, surgical correction can produce good results.

Keywords: scapulothoracic bursitis; shoulder; snapping scapula.

Figure 1.

A, in this axial view of the scapulothoracic articulation, 2 major anatomic bursae can be seen: the supraserratus bursa and the infraserratus bursa; B, minor adventitial bursae of the scapulothoracic articulation are believed to develop in response to pathomechanics—they include 2 infraserratus bursae, a supraserratus bursa, and a trapezoid bursa.

Figure 2.

The rehabilitation protocol should include scapular core exercises such as scaption, or elevation in the scapular plane.

Figure 3.

Scapulothoracic injection at the medial border of the scapula. The limb is placed in the “chicken wing” position.

Figure 4.

Resection of the superomedial border of the scapula: A, after an incision is made over the medial spine of the scapula, the trapezius muscle is elevated from the spine; B, the supraspinatus, rhomboids, and serratus muscles are reflected, and the superomedial angle of the scapula is resected; C, the supraspinatus is sutured through drill holes to the spine of the scapula.

Figure 5.

Development of an infraserratus bursa at the inferior angle of the scapula in a baseball pitcher.

Figure 6.

Portals used for bursectomy in arthroscopic treatment of scapulothoracic bursitis and crepitus.