snapping scapular syndrome

[TIVAndy]

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i just had a young guy walk in with severe pain in both scapular - he showed me the sounds that his scapula made - it was quite impressive.
he was asking about scapulothoracic bursa injection - anyone have experience with this? US guided? it seems pretty simple enough and you need to make sure you don't hit the lung..

 

[oreosandsake]

would love to see where it hurts for him under US. you can probably find the place of limitation / rubbing and put the medication right there.

 

[pmrmd]

I’ve done it under fluoro several times. Steroid was okay. I had decent results with large volumes of saline and hydrodissection.

 

[fentanyl patch]

i just had a young guy walk in with severe pain in both scapular - he showed me the sounds that his scapula made - it was quite impressive.
he was asking about scapulothoracic bursa injection - anyone have experience with this? US guided? it seems pretty simple enough and you need to make sure you don't hit the lung..

I've done quite a few scapulothoracic bursa injections under US.
Pretty easy to do, but results are mixed; likely due to incorrect diagnosis.
Overall, scapular pain remains a bit of a mystery to me.
I've had normal-appearing patients with severe scapular pain.
I occasionally order MRI's of the scapula but never find anything.

If anyone has any insights here, I'd appreciate it as well.

 

[Baron Samedi]

It's actually a really easy landmark injection. Have the patient lie prone, put their arm behind their back which will elevate the scapula, and put a 27G needle right under it while keeping your needle parallel to the scapula to avoid injecting deep into pleura.

 

[deleted993114]

i just had a young guy walk in with severe pain in both scapular - he showed me the sounds that his scapula made - it was quite impressive.
he was asking about scapulothoracic bursa injection - anyone have experience with this? US guided? it seems pretty simple enough and you need to make sure you don't hit the lung..

Bernie Abrams was always big on that. He claimed it worked pretty well. I think that a lot of it is a misdiagnosis and a referred sclerotomal pain from C6/C7

 

[Baron Samedi]

Also if the diagnosis isnt clear, consider cervical facet disease and also I've seen a few cervical radiculopathies present with periscapular pain.

 

[SommeRiver]

I do this injxn off palpation and landmarks. Agree with above technique, but what I do is have patient hang arm off table, and then slowly have them retract the scapula while placing their hand on the lower back. I have my finger under the scapula throughout the entire movement.

I'm not sure there is a good reason to use US for this, and these only occasionally work for me, but keep in mind scapulotrapezial, infraserratus, and inferior scapulothoracic bursitis are not the same diagnoses as snapping scapula syndrome, which is a mechanical pathology in my mind.

Not sure an inflamed bursa causes snapping as my understanding is more of an atrophic process where the scapula rubs across the ribs bc the subscapularis isn't providing a big enough lift off.

Could be wrong on the bursa thing though.

 

[tmvguy03]

i just had a young guy walk in with severe pain in both scapular - he showed me the sounds that his scapula made - it was quite impressive.
he was asking about scapulothoracic bursa injection - anyone have experience with this? US guided? it seems pretty simple enough and you need to make sure you don't hit the lung..

Ive had a couple people like this. Tried injections (USGI) and cervical facets with variable outcomes. I ended up sending one lady to a MIS guy in Vail,CO who did scapula arthroscopy- and her symptoms are gone. Both pain and the snapping/popping which were also impressive. I was frankly surprised, but would send him patients in the future based on her positive experience and results.
She was on 20 OME for >1yr and titrated off post op.

 

[TIVAndy]

I do this injxn off palpation and landmarks. Agree with above technique, but what I do is have patient hang arm off table, and then slowly have them retract the scapula while placing their hand on the lower back. I have my finger under the scapula throughout the entire movement.

I'm not sure there is a good reason to use US for this, and these only occasionally work for me, but keep in mind scapulotrapezial, infraserratus, and inferior scapulothoracic bursitis are not the same diagnoses as snapping scapula syndrome, which is a mechanical pathology in my mind.

Not sure an inflamed bursa causes snapping as my understanding is more of an atrophic process where the scapula rubs across the ribs bc the subscapularis isn't providing a big enough lift off.

Could be wrong on the bursa thing though.

i think you are correct. snapping scapula occurs with sometimes atrophy of subscapularis - that being said my guy definitely makes large snapping sounds with his scapula. it maybe worth getting a MRI perhaps..

 

[TIVAndy]

Ive had a couple people like this. Tried injections (USGI) and cervical facets with variable outcomes. I ended up sending one lady to a MIS guy in Vail,CO who did scapula arthroscopy- and her symptoms are gone. Both pain and the snapping/popping which were also impressive. I was frankly surprised, but would send him patients in the future based on her positive experience and results.
She was on 20 OME for >1yr and titrated off post op.

mind sharing who this surgeon is?

 

[tmvguy03]

mind sharing who this surgeon is?

Sure, his name is Peter Millett. I only have sent him the one patient, but she had a remarkable outcome. I think he may do free image reviews?

 

[Baron Samedi]

There's a few diagnostic things I think about with snapping scapula, some already mentioned:
1. Subscapularis atrophy -- the differential for this is rather broad. I think most cases are probably degenerative secondary to a tendon tear, but I also think about things like C5-6 radiculopathy, brachial plexus injury, Parsonage Turner syndrome, disuse atrophy, and body habitus(very skinny patients)
2. Serratus anterior pathology -- similar to the above. I had a young lady with a profound LTN injury after trauma with severe subscapular pain and crepitus.
3. Bony or soft tissue pathology -- the most likely being an osteochondroma, especially given the age group. I've read about soft tissue tumors in the thoracic wall that can present similarly. A previous history of rib fractures or a scapular fracture could also have this sort of sequelae.
4. Subscapularis bursitis -- as mentioned above, there are several bursa in this area that can cause symptoms. I think any of the above etiologies could cause mechanical irritation and enlarge the bursa. I've never seen it appear on an MRI, but reading about it there can be an actual cystic formation of the bursa if it becomes significantly inflamed which could obviously lead to mechanical symptoms.