Shoulder and Elbow cases scapulothoracic bursitis

A 50-year-old, right-hand-dominant female presents to clinic with posterior right shoulder pain and sometimes a loud noise while using her right upper extremity for overhead activities. Her pain is concentrated over the superomedial border of her scapula, but she also says her pain is underneath her shoulder blade. What is most bothersome is the fact that she is unable to brush her hair because of the discomfort she experiences. She reports that it started as only noise several years prior, but over the last several months she has developed debilitating pain with overhead activities. She works as a salon hair stylist and denies a history of trauma to her right upper extremity.

Which of the following is the most likely diagnosis?

1. Impingement syndrome

2. Rotator cuff tendinitis

3. Suprascapular nerve entrapment

4. Supraspinatus muscle tear

5. Scapulothoracic bursitis

Discussion

The correct answer is (E). Scapulothoracic bursitis is commonly known as snapping scapula syndrome. This syndrome can be classified on the basis of the cause, which can result in either scapulothoracic crepitus or scapulothoracic bursitis. However, these can many times be indistinguishable in clinical practice because mechanical crepitus can lead to symptomatic bursitis, and conversely, symptomatic bursitis can lead to mechanical crepitus. The woman in this case likely developed bursitis from her mechanical crepitus because she was experiencing a noise without pain for several years. Scapulothoracic crepitus has been found in 31% of 100 normal asymptomatic people. Patients with scapulothoracic bursitis have often experienced symptoms for a long period of time, and these symptoms can range from mild, intermittent discomfort to notable functional disability. Common complaints are that symptoms are causing a decrease in athletic performance or pain with overhead activities. When obtaining the patient’s history, it is important to know their hand dominance, occupation, and activity level. Impingement syndrome, rotator cuff tendinitis, and a supraspinatus tear are less likely in this case given the history of a loud noise prior to the pain and the location of the pain. Answer C is incorrect because the patient is not complaining of weakness.

When examining a patient with suspected scapulothoracic bursitis it is not only important to evaluate bilateral scapula, but also crucial to closely examine which of the following?

1. Cervical and thoracic spine

2. Lumbar spine

3. Ipsilateral sternoclavicular range of motion

4. Biceps brachii motor strength

 

Discussion

The correct answer is (A). When examining patients with scapulothoracic bursitis, it is important to examine the cervical and thoracic spine for fixed or postural kyphosis that may contribute to scapulothoracic incongruity. Evaluation of the cervical spine should also be performed to rule out referred pain. Inspection of each scapula should include looking for asymmetry, winging, or audible snapping. It is important to specifically test muscle strength of the trapezius, rhomboid, levator scapulae, serratus anterior, and latissimus dorsi muscles. Weakness in any of these can cause imbalances leading to a pathologic state. The lumbar spine should not affect scapulothoracic bursitis. The ipsilateral sternoclavicular joint and biceps

brachii muscle should be evaluated, but this is not critical to the diagnosis of scapulothoracic bursitis.

The patient’s symptoms fail to improve after 6 months of conservative management, including activity modification, physical therapy (PT), nonsteroidal anti-inflammatory drugs, and ultrasound guided injections. The injections provided short-term relief. Radiographs and a three-dimensional CT scan were obtained. The patient had an anterior “horn-like” projection at the superomedial angle of the scapula. Surgical intervention is planned using a modified mini-open approach with arthroscopy-assisted bursectomy. Portals are placed 3 cm medial to the medial scapular border.

Which structure(s) are avoided with this portal placement?

1. Long thoracic nerve

2. Suprascapular nerve

3. Dorsal scapular artery and nerve

4. Transverse cervical artery

5. Spinal accessory nerve

 

Discussion

The correct answer is (C). The dorsal scapular artery and nerve travel beneath the rhomboid minor and major muscles approximately 1 to 2 cm medial to the medial scapular border. Portal placement should therefore be located approximately 3 cm medial to the medial scapular border (Fig. 2–80).

 

 

 

Figure 2–80 Reproduced with permission from Warth, RJ, Spiegl UJ, Millet PJ. Scapulothoracic bursitis and snapping scapula syndrome: a critical review of current evidence. Am J Sports Med 2014 Mar 24. [Epub ahead of print]

 

Answer A is incorrect because the long thoracic nerve is rarely endangered unless dissection is carried lateral. The suprascapular nerve can be endangered if a portal is placed superior to the scapular spine. The deep branch of the transverse cervical artery becomes the dorsal scapular artery. The spinal accessory nerve travels with the superficial branch of the transverse cervical artery, and its branches are at risk if a portal is placed superior to the scapular spine. Scapulothoracic bursitis is usually managed nonoperatively. Nonoperative treatment includes activity modification, NSAIDs, PT, and corticosteroid injections. If symptoms are recalcitrant to conservative management or associated with an osseous or soft tissue mass, surgical intervention is indicated. Arthroscopic, open, or a combined operative approach can be performed. Arthroscopy is more technically demanding, but it does not require postoperative immobilization because the rhomboids and levator scapulae are not transected and reattached to the scapula after partial scapula resection is performed.

As mentioned, radiographs and a CT were obtained. If an osseous lesion is suspected, the threshold to obtain three-dimensional imaging should remain low. MRI can be used to identify soft tissue lesions and to help prevent misdiagnoses and unnecessary surgical intervention. Ultrasound has been used to identify inflamed bursal tissue, although it is more commonly used for diagnostic and therapeutic injections. Electromyogram can sometimes be necessary for patients with imbalances in the periscapular musculature and asymmetry.

A superomedial scapular resection as well as bursectomy is performed. While dissecting laterally, the suprascapular notch becomes visible in the operative field. What structure runs superficial to the transverse scapular ligament?

1. Suprascapular nerve

2. Transverse cervical artery

3. Spinal accessory nerve

4. Suprascapular artery

5. Long thoracic nerve

 

Discussion

The correct answer is (D). The suprascapular artery runs superficial to the transverse scapular ligament. The suprascapular nerve travels deep to the ligament. Answers B, C, and E are not closely associated with the transverse scapular ligament.

What is the ideal patient position for both injections and operative treatment of scapulothoracic bursitis?

1. Prone with affected arm in 90 degrees of abduction and internally rotated

2. Prone with affected arm in extension and internal rotation

3. Lateral decubitus with affected arm adducted and externally rotated

4. Prone with affected arm adducted and externally rotated

 

Discussion

The correct answer is (B). The so-called chicken-wing position is utilized to elevate the medial border of the scapula to gain access to both the superior and inferior bursa (Fig. 2–81).

 

 

 

Figure 2–81 (From Lazar MA, Kwon YW, Rokito AS. Current concepts review: snapping scapula syndrome. J Bone Joint Surg Am. 2009;91:2251–2262.)

 

Answers A, C, and D are incorrect because none of these positions would help to elevate the medial border of the scapula. The scapulothoracic articulation is unique because it does not rely on hyaline cartilage, but rather muscle layers and interposing bursal tissue to achieve smooth motion. Symptoms can result from overuse and inflammation of this bursal tissue or can be caused by bony abnormality. Periscapular bursae include infraserratus, supraserratus, and scapulotrapezial bursa. Symptoms over the superomedial scapula area could be caused by the infraserratus or supraserratus bursae. Occasionally, patients will have symptoms localized to the medial border of the scapula at the level of scapular spine, which can be attributed to inflammation of the scapulotrapezial bursa.

 

Objectives: Did you learn …?

 

Diagnose scapulothoracic bursitis?

 

Recognize the different names for scapulothoracic bursitis and that crepitus can lead to bursitis and vice-versa?

 

Understand how to conservatively and surgically manage scapulothoracic bursitis?

 

Understand common complications associated with performing surgery for scapulothoracic bursitis?