Snapping Scapula Syndrome (SSS) includes pathologies of the bone structures and soft areas of the scapula, which are manifested by pain, audible crackles, or a feeling of jumping the scapula. Symptoms occur when making shoulder movements and raising the arm above the head. The essence of the disease are structural changes in the scapula itself and the muscles lying between the scapula and the back wall of the chest in the so-called scapulo-costal space. The pathologies associated with the crackling scapula syndrome also include inflammation of the surrounding bursitis, the role of which is to facilitate the sliding of the scapula along the back wall of the chest.
The cause of the disease is a disturbance in the biomechanics of the movement of the scapula and tissue overload due to frequent overhead activities. Diagnostics consists mainly in the functional examination of the brachiocapular complex and the analysis of imaging examinations. Treatment of lighter forms of crackling scapulae includes rehabilitation, the main task of which is to improve the biomechanics of the scapula movement. Structural changes causing tissue conflict and the lack of improvement in spite of conservative treatment attempts are an indication for surgical treatment. The procedure can be performed using the classic open method as well as the less invasive arthroscopic method.
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Anatomy
The shoulder blade is a flat bone of a triangular shape located behind the shoulder on the back wall of the chest. The shoulder blade is connected to the rest of the shoulder complex only through:
the shoulder-clavicle joint formed by the articular surface of the shoulder process of the scapula and the shoulder end of the clavicle,
Shoulder joint formed by the articular cavity of the scapula and the head of the humerus.
The shoulder blade is "suspended" on the muscles - its position, stability and mobility during movements depend mainly on the activities of the muscles that connect the shoulder blade with the chest and spine.
The movements of the scapula make it possible to increase the range of mobility of the shoulder complex - the shoulder is raised to the horizontal in the shoulder joint, while the continuation of the shoulder lifting movement above the right angle is associated with the movement of the shoulder blade, which slides along the back wall of the chest. The shoulder blade also moves when extending, retracting, lifting and lowering the shoulder. The movements of the scapula occur in many directions (pic. 1).
During the movements of the scapula, the structures within the scapulo-costal space slip:
between the anterior dentate muscle and the chest,
between the dentate anterior muscle and the subscapular muscle.
Slip in individual layers is facilitated by bursae, i.e. products of the synovial membrane with a smooth and slippery surface, producing synovial fluid.
Crackling scapula syndrome - causes, symptoms
Ailments of the shooting scapula may result from:
conflict of degenerative and productive changes, e.g. cartilage and bone growths within the scapula or ribs,
injuries of the subscapular or dentate anterior muscle,
hypertrophy and inflammation of the synovial bursitis,
post-traumatic and post-inflammatory adhesions within the tissues lying in the scapulo-costal space.
The symptoms of crackling scapula syndrome depend on the structure involved in the pathology. Jumping in the shoulder blade and crackling noises are expressions of a structural conflict that may or may not be painful. Pain in the area of the scapula without jumping over it, on the other hand, may be related to the inflammation of the synovial bursa. Symptoms appear when the limb reaches over the head and when making movements with the shoulder girdle, e.g. shrugging the shoulders or moving back and extending the shoulders.
The severity of the symptoms depends on the degree of tissue irritation. The chronic condition of the disease is characterized only by the presence of crunching and jumping noises in the shoulder blade. Failure to undertake appropriate treatment and further overloading of the structures under the scapula may lead to their damage and pain. In the acute stage, pain can be present even at rest.
The development of pathological changes is related to the disturbance of the biomechanics of the scapula movement, the so-called dyskinesia. Scapular dyskinesia is characterized by too early onset of scapula motion and an abnormal path of motion. This may be due to abnormal muscle tone, contractures, weakness in the shoulder girdle muscles, and impaired activation of the muscles by the central nervous system. Such conditions are typical in people after injuries and after surgeries in the shoulder girdle, and after long-term immobilization of the shoulder. The risk of scapula dyskinesia is also greater in people with postural defects, such as an excessively rounded back in the thoracic region (hyperphosis).
Tissue overload contributes to the development of a shooting scapula, which occurs in connection with frequently repeated activities performed over the head. The crackling blade syndrome is common among athletes (volleyball players, people training throwing disciplines) and construction workers (plasterers, painters).
Crackling Blade Syndrome - Diagnostics
Initial diagnosis of "crackling blade syndrome" is possible on the basis of a clinical examination. The orthopedic surgeon asks the patient to perform an upper limb abduction movement, during which he palpates the area of the scapula. A common place of conflict is the upper angle of the scapula - pressing it against the chest may increase pain and / or crackling. The deep pain in the area of the upper edge or lower angle of the scapula rather suggests that the synovial bursa is inflamed.
The type of pathological changes in the popping scapula syndrome can be more accurately determined by performing imaging studies. X-rays show the presence of bone outgrowths or free bodies in the scapulo-costal space. On the other hand, magnetic resonance imaging shows inflammation, damage or soft tissue fibrosis.
Conservative treatment
Rehabilitation treatment is carried out in the case of a conflict of soft tissues, bad position of the scapula due to disturbances in the length and tension of the muscles and accompanying posture defects. The main goal of the therapy is to restore the correct movement patterns of the scapula. First, the physiotherapist uses manual therapy techniques to release soft tissues from possible adhesions. Then he uses methods to normalize muscle tension and lengthen shortened muscles. The first exercises for the slamming scapula syndrome involve activating the appropriate muscles that control the movements of the scapula. Gradually, the patterns of the entire upper limb are included, while maintaining the correct shoulder-scapular rhythm. The movements performed must take into account the mutual harmony of the biomechanics of the shoulder blade and the shoulder joint. At the end, strength and endurance exercises of the upper limb and elements of the practiced sports discipline are included.
Bursitis can be treated as an adjunct with physical therapy procedures. Persistent inflammation may require the injection of a steroid into the bursa.
Slamming scapula surgery
The indications for surgical treatment are the presence of bone deformities which are the cause of the conflict, the presence of free bodies in the scapulo-costal space, and tissue pathologies that can only be treated surgically. The most common procedure is the excision of the bone growths of the upper or lower edge of the scapula and the release of connective tissue adhesions. If necessary, the thickened synovial bursa is also removed.
The procedure can be performed using the classic open method or the less invasive arthroscopic method. Both methods are equally effective provided that the patient is properly qualified and the operator's experience. In the arthroscopic procedure, the surgeon makes 2-3 small holes (up to 4mm) through which he introduces the surgical instruments and the camera into the scapulo-costal space. Scars after the procedure are minimal and the patient returns to full fitness faster.
In the Dworska Hospital, after surgical procedures, a special Game-ready device is used, which cools and at the same time optimally compresses the shoulder and shoulder blade area. This procedure significantly increases the comfort and well-being after the surgery, reducing swelling and eliminating pain. Thanks to this, the patient can start rehabilitation faster. Physiotherapy begins as early as 2-3 days after the procedure and its aim is to restore the painless range of mobility of the shoulder girdle, restore the correct scapula patterns, and strengthen the muscles. For a period of 4 weeks after the surgery, it is advisable to secure the upper limb with a sling, which is removed during rehabilitation.
The time to return to full activity is an individual matter - it depends on the number of procedures performed during the surgery and the functional state of the shoulder girdle before the procedure. Most patients are able to return to the profession or start light sports training in the third month after surgery.
Sources:
Merolla, Giovanni et al. “Snapping Scapula Syndrome: Current Concepts Review in Conservative and Surgical Treatment.” Muscles, Ligaments and Tendons Journal 3.2 (2013): 80–90.
FAQs: Frequently asked questions about crackling scapula syndrome treatment:
Symptoms, including pain, the feeling of skipping the shoulder blade, and the presence of an audible click when moving the shoulder may be a sign of the so-called snapping scapula syndrome. The cause of the disease is structural changes leading to a mechanical conflict of the bone or soft tissues lying under the scapula. Pain under the scapula without the feeling of skipping may be related to the inflammation of the subscapular bursa. In order to determine the cause of the ailments, you should go to an orthopedist who will perform a detailed clinical examination and order additional imaging tests. Early diagnosis and treatment of "popping scapulae syndrome" is very important - ignoring the symptoms can lead to a progression of structural changes that can only be treated with surgery.
The main goal of rehabilitation is to restore the correct movement patterns of the scapula, which will not overload the tissues lying in the subscapular area. The first stage of physiotherapy includes methods to normalize muscle tension and to extend the shortened muscles to restore the normal mobility (mobility) of the shoulder blade. The crackling scapula exercises involve activating the appropriate muscles to achieve the required scapula stabilization. Gradually, the patterns of the entire upper limb are included, while maintaining the correct biomechanics of the scapula and the shoulder joint. The last stage of rehabilitation is strength and endurance exercises of the upper limb and elements of the sports discipline. The therapy process should be carried out under the supervision of an experienced physiotherapist.
The indication for surgical treatment is the presence of degenerative-productive bone changes, free bodies in the scapulo-costal space and other pathologies that cannot be rehabilitated. The most common procedure is the excision of the bone growths of the upper or lower edge of the scapula and the release of connective tissue adhesions that cause jumping and pain under the scapula. If necessary, the pathologically thickened synovial bursa are also removed.
