Scapulothoracic Bursitis is a medical term for the condition which causes pain in the region of the scapula in the back of the shoulder. This condition is often associated with audible and palpable crepitation, and so it has also been named “snapping scapular syndrome. A bursa (fluid-filled sac) is located between the scapula and the thorax (rib cage). The bursa provides cushioning and protection against friction during the movement of the shoulder blade relative to the rib cage. This fluid sac is known as the scapulothoracic bursa. Snapping scapula syndrome can be a painful shoulder condition for many patients. The most common symptoms include a dull, contact ache accompanied by grinding, grating, and snapping sensation along the underside of the scapula when it moves against the ribcage.
Scapulothoracic bursitis is a rare disease; its pathogenesis is known to be related to chronic repetitive mechanical stress of periscapular tissue, usually resulting from a bone abnormality such as a protrusion of the scapula or rib cage
Other Names
- Subscapular Bursitis
- Scapulothoracic Crepitus
- Snapping Scapula Syndrome
- Scapulocostal Syndrome
- Washboard Syndrome
Pathophysiology
Etiology
- Carlson et al
- Skeletal abnormalities (43%)
- Idiopathic (30%)
- History of first rib resection (15%)
- Muscle or bursal changes (10%)
- Mccluskey et al: trauma reported in 6 of 9 cases including MVC, fall on the outstretched extremity
- Overuse injuries including overhead sports (swimming, throwing, raquet sports)
- Sisto et al: seen in MLB pitchers due to flawed throwing mechanics
- Bony abnormalities
- Most commonly osteochondroma which can arise from ribs or scapula
- Can lead to “pseudo-winging” due to lesion mechanically forcing scapula away from the chest wall
- Luschka’s tubercle has been implicated
- Malunion of rib fractures, scapula fractures are known causes
- Muscle pathology
- Includes fibrotic muscle, atrophy, edema, and anomalous muscle insertions
- Other soft tissue pathology
- Syphilis or tuberculosis lesions
- Elastofibroma Dorsi
- Structural abnormalities
- Primarily spinal including scoliosis and kyphosis
Pathoanatomy
- Scapulothoracic Joint
- Scapulothoracic muscles (coordinate scapulothoracic motion)
- Trapezius
- Serratus Anterior
- Levator Scapulae
- Rhomboid Major
- Pectoralis Minor
- Scapulohumeral muscles: provide power to the Humerus
- Rotator Cuff (also regulate activities of the Glenohumeral Joint)
- Coracobrachialis
- Deltoid
- Teres Major
- Bursa
- Infraserratus bursa: between Serratus Anterior and chest wall
- Supraserratus bursa: between Subscapularis and serratus anterior
- Minor bursa inconsistently found at
- Superomedial angle of scapula
- Inferior angle of the scapula
- Trapezoid bursa
- Sports
- Pitching
- Swimming
- Football
- Gymnastics
- Weight training
- Occupations (which?)
- Scoliosis
- Kyphosis
Differential Diagnosis
- Fractures
- Proximal Humerus Fracture
- Humeral Shaft Fracture
- Clavicle Fracture
- Scapula Fracture
- First Rib Fracture (traumatic or atraumatic)
- Dislocations & Seperations
- Acromioclavicular Joint Separation
- Glenohumeral Dislocation (Acute)
- Sternoclavicular Joint Dislocation
- Glenohumeral Instability (Chronic)
- Arthropathies
- Glenohumeral Arthritis
- Acromioclavicular Joint Arthritis
- Muscle & Tendon Injuries
- Pectoralis Major Injuries
- Pectoralis Minor Injuries
- Proximal Biceps Tendon Injuries
- Scapular Dyskinesis
- Rotator Cuff
- Rotator Cuff Tear
- Rotator Cuff Tendonitis
- Calcific Tendinitis of the Rotator Cuff
- Subcoracoid Impingement Syndrome
- Bursopathies
- Subacromial Bursitis
- Scapulothoracic Bursitis
- Ligament Injuries
- Glenoid Labral Tears
- Neuropathies
- Suprascapular Nerve Injury
- Parsonage-Turner Syndrome
- Quadrilateral Space Syndrome
- Winged Scapula
- Other
- Adhesive Capsulitis
- Paget-Schroetter Syndrome
- Pediatrics
- Coracoid Avulsion Fracture
- Humeral Head Epiphysiolysis (Little League Shoulder)
Diagnosis
- General: Physical Exam Shoulder
- History
- May endorse a history of overhead or overuse sports
- Often complain of pain with activity
- May report crepitus or crackling with the movement of the scapula
- Physical
- Crepitus may be reproducible with the range of motion of the scapula
- Tenderness if present is most common at the medial border of the scapula[8]
- Inspection may reveal scapular winging which suggests a space-occupying lesion
- Scapular dyskinesis
- Radiographs
- Standard Radiographs Shoulder
- Often normal, useful to exclude osseous etiologies
- CT
- Useful if a physician suspects bony etiology with normal radiographs
- One study used 3-dimensional CT reconstruction of the scapula and chest wall found bony abnormalities in 26/26 patients[9]
- MRI
- Useful to evaluate for soft tissue lesions
- Corticosteroid Injection
- Injection of corticosteroid and/or local anesthetic can be used to help confirm diagnosis
- This should be performed with ultrasound or fluoroscopy
- EMG/NCS
- Should be considered if any muscle weakness or atrophy
Treatment
Nonoperative
- First line therapy in most cases
- Most beneficial if etiology is one of the following
- Soft tissue disorder
- Altered posture
- Scapular dyskinesia
- Scapular winging
- Treatment
- Rest
- Medications including NSAIDS, Acetaminophen
- Activity modification
- Physical Therapy
- Emphasis on periscapular muscles, rotator cuff and posture
- Consider Iontophoresis[10], topical Ethyl Chloride[11]
- Corticosteroid Injection under ultrasound guidance
- Other considerations
- Figure of 8 Splint may help with posture
Operative
- Indications
- Refractory to non-operative management
- Mass or aggressive lesion
- Technique
- Bursectomy
- Resection of osseous lesion
- Resection of scapular border
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